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Chin ZY, Thian YL, Lim YT. MR Evaluation of an Unusual Intruder of the Bladder: A Bladder Fibroid Case Report. Curr Med Imaging 2024; 20:CMIR-EPUB-138791. [PMID: 38676516 DOI: 10.2174/0115734056281515240109080108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/18/2023] [Accepted: 11/22/2023] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Mesenchymal tumours of the bladder are benign but rare occurrences and represent approximately 1% of all bladder tumours. CASE REPORT We report a case of a large bladder leiomyoma in an asymptomatic patient. A large pelvic mass was discovered incidentally on the bedside ultrasound scan during a review at the gynecology clinic. Intra-operatively, no mass was seen in the pelvis, and cystoscopy demonstrated an intravesical mass. It was further evaluated with cystoscopy. MR imaging demonstrated typical features of a bladder leiomyoma. Subsequently, the patient underwent partial cystectomy, and the mass was removed, which was histologically proven leiomyoma. CONCLUSION Awareness of this rare clinical entity and identification of its typical radiological features on MR imaging can aid with accurate diagnosis and preclude unnecessary radical surgery.
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Affiliation(s)
- Zong Yi Chin
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Yee Liang Thian
- Department of Diagnostic Imaging, National University Hospital, Singapore
| | - Yi Ting Lim
- Department of Diagnostic Imaging, National University Hospital, Singapore
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Okoro CC, Ikpeze OC, Eleje GU, Udigwe GO, Ezeama CO, Ugboaja JO, Enechukwu CI, Umeononihu OS, Ogabido CA, Oguejiofor CB, Njoku TK, Egeonu RO, Okafor CG, Obiagwu HI, Onyejiaka CC, Obidike AB, Onah CE, Uzukwu I, Okoro AD, Ezema EC, Ibekwe AM, Ikechebelu JI. Association between serum vitamin D status and uterine leiomyomas: a case-control study. Obstet Gynecol Sci 2024; 67:101-111. [PMID: 37848168 DOI: 10.5468/ogs.23143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/27/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE Uterine leiomyoma is a common gynecological condition that negatively affects women's quality of life. Vitamin D plays an important role in tumor development and progression. However, clinical studies comparing serum vitamin D levels between women with and without uterine leiomyomas are limited and inconclusive. This study aimed to compare serum vitamin D levels in women with and without uterine leiomyomas. METHODS This hospital-based case-control study included 150 women who visited a gynecological clinic. The cases included 75 women with uterine leiomyoma, whereas the controls included 75 age-and parity-matched participants without uterine leiomyoma. Serum vitamin D levels were measured in each participant and volumes of the uterine leiomyomas were determined using the water displacement method following myomectomy. The statistical significance was inferred at P<0.05. RESULTS The mean serum vitamin D level was 15.26±4.96 ng/mL and 22.45±6.93 ng/mL for the case and control groups, respectively. The difference was statistically significant (t-value -7.302 and P<0.001). Within the fibroid group, nine (12.0%), 49 (65.33%), and 17 (22.67%) participants had vitamin D deficiency, insufficiency, and sufficiency, respectively; and in the control group, two (2.67%), 24 (45.33%), and 39 (52.0%) participants had vitamin D deficiency, insufficiency, and sufficiency, respectively. There was significant negative correlation between the fibroid volume and the serum vitamin D level (r=-0.591, P<0.001). CONCLUSION Women with uterine leiomyoma had lower vitamin D levels than women in the control group. Lower vitamin D levels were associated with larger fibroid masses. Therefore, vitamin D supplementation may reduce fibroid growth and development.
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Affiliation(s)
| | - Okechukwu Christian Ikpeze
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - George Uchenna Eleje
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Gerald Okanandu Udigwe
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Chukwuemeka Okwudili Ezeama
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Joseph Odirichukwu Ugboaja
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Chukwunonso Isaiah Enechukwu
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
| | - Osita Samuel Umeononihu
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Chukwudi Anthony Ogabido
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Charlotte Blanche Oguejiofor
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Tobechi Kingsley Njoku
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
| | - Richard Obinwanne Egeonu
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
| | - Chigozie Geoffrey Okafor
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
| | - Hillary Ikechukwu Obiagwu
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
| | | | - Afam Ben Obidike
- Department of Anaesthesiology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
| | - Christian Ejike Onah
- Department of Medical Laboratory Sciences, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
| | - Ifeanyi Uzukwu
- Department of Radiology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
| | | | | | - Adaobi Maryann Ibekwe
- Department of Nursing Sciences, Chukwuemeka Odumegwu Ojukwu University, Igbariam, Nigeria
| | - Joseph Ifeanyichukwu Ikechebelu
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University Teaching Hospital Nnewi, Nnewi, Anambra, Nigeria
- Department of Obstetrics & Gynecology, Nnamdi Azikiwe University, Nnewi, Anambra, Nigeria
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Chuang TD, Ton N, Rysling S, Quintanilla D, Boos D, Khorram O. Therapeutic effects of in vivo administration of an inhibitor of tryptophan 2,3-dioxygenase (680c91) for the treatment of fibroids: a preclinical study. Fertil Steril 2023:S0015-0282(23)02073-3. [PMID: 38072367 DOI: 10.1016/j.fertnstert.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/16/2023] [Accepted: 12/04/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVE Fibroids are characterized by marked overexpression of tryptophan 2,3 dioxygenase (TDO2). The objective of this study was to determine the effectiveness of in vivo administration of an inhibitor of TDO2 (680C91) on fibroid size and gene expression. DESIGN Animal and ex vivo human study. SETTING Academic Research Institution. SUBJECTS Severe combined immunodeficiency mice bearing human fibroid xenografts treated with vehicle and TDO2 inhibitor. INTERVENTION Daily intraperitoneal administration of 680C91 or vehicle for 2 months and in vitro studies with fibroid explants. MAIN OUTCOME MEASURES Tumor weight and gene expression profile of xenografts and in vitro mechanistic experiments using fibroid explants. RESULTS Compound 680C91 was well-tolerated with no effects on blood chemistry and body weight. Treatment of mice with 680C91 resulted in 30% reduction in the weight of fibroid xenografts after 2 months of treatment and as expected lower levels of kynurenine, the byproduct of tryptophan degradation and an endogenous ligand of aryl hydrocarbon receptor (AhR) in the xenografts. The expression of cytochrome P450 family 1 subfamily B member 1 (CYP1B1), transforming growth factor β3 (TGF-β3), fibronectin (FN1), cyclin-dependent kinase 2 (CDK2), E2F transcription factor 1 (E2F1), interleukin 8 (IL-8) and secreted protein acidic and cysteine rich (SPARC) mRNA were lower in the xenografts of mice treated with 680C91 compared with vehicle controls. Similarly, the protein abundance of collagen, FN1, CYP1B1, and SPARC were lower in the xenografts of 680C9- treated mice compared with vehicle controls. Immunohistochemical analysis of xenografts indicated decreased expression of collagen, Ki67 and E2F1 but no significant changes in cleaved caspase 3 expression in mice treated with 680C91. The levels of kynurenine in the xenografts showed a direct correlation with the tumor weight and FN1 levels. In vitro studies with fibroid explants showed a significant induction of CYP1B1, TGF-β3, FN1, CDK2, E2F1, IL8, and SPARC mRNA by tryptophan, which could be blocked by cotreatment with 680C91 and the AhR antagonist CH-223191. CONCLUSION The results indicate that correction of aberrant tryptophan catabolism in fibroids could be an effective treatment through its effect to reduce cell proliferation and extracellular matrix accumulation.
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Affiliation(s)
- Tsai-Der Chuang
- Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, Torrance, California; The Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Nhu Ton
- The Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Shawn Rysling
- The Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Derek Quintanilla
- The Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Drake Boos
- The Lundquist Institute for Biomedical Innovation, Torrance, California
| | - Omid Khorram
- Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, Torrance, California; The Lundquist Institute for Biomedical Innovation, Torrance, California; Department of Obstetrics and Gynecology, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California.
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Santalla-Hernández A, Naveiro-Fuentes M, Benito-Villena R, Villegas-Alcazar J, López-Criado MS, Lara-Serrano A, Parra JF, Alcázar JL, Pelayo-Delgado I. Complications of transvaginal radiofrequency ablation of fibroids: A 5-year experience. Eur J Obstet Gynecol Reprod Biol X 2023; 20:100244. [PMID: 37869066 PMCID: PMC10587728 DOI: 10.1016/j.eurox.2023.100244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
Introduction Transvaginal radiofrequency ablation is a relatively noninvasive approach for the treatment of fibroids in patients who do not wish to undergo conventional surgery. Information on potential complications of this novel technique is very scarce. Methods Retrospective, descriptive, epidemiological study of 115 patients who underwent transvaginal radiofrequency ablation of fibroids and for whom complications were recorded. Results We performed 115 transvaginal radiofrequency ablation procedures, we recorded a total of 11 complications (9.6%; 95% CI, 3.8-14.8). Of these, 8 (7.0%) were classified as Clavien-Dindo type I, 1 (0.9%,) as type II, and 2 (1.7%) as type IIIb (severe). No other complications were recorded in a year follow-up. Conclusion Transvaginal radiofrequency ablation is a treatment option that makes it possible to treat fibroids that are difficult to manage using other techniques. Few associated complications have been described, and most of them are mild.
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Affiliation(s)
- Angel Santalla-Hernández
- Obstetrics and Gynecology department, Virgen de las Nieves University Hospital, 18014 Granada, Spain
| | - Mariña Naveiro-Fuentes
- Obstetrics and Gynecology department, Virgen de las Nieves University Hospital, 18014 Granada, Spain
| | - Rebeca Benito-Villena
- Obstetrics and Gynecology department, Virgen de las Nieves University Hospital, 18014 Granada, Spain
| | - Jesus Villegas-Alcazar
- Obstetrics and Gynecology department, Virgen de las Nieves University Hospital, 18014 Granada, Spain
| | | | - Ana Lara-Serrano
- Obstetrics and Gynecology department, Virgen de las Nieves University Hospital, 18014 Granada, Spain
| | - Jorge Fernández Parra
- Obstetrics and Gynecology department, Virgen de las Nieves University Hospital, 18014 Granada, Spain
- PhD. Program in clinical medicine and Public Health, University of Granada,18006 Granada, Spain
| | - Juan Luis Alcázar
- Obstetrics and Gynecology Department. Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Irene Pelayo-Delgado
- Obstetrics and Gynecology Department, Ramón y Cajal University Hospital, Faculty of Medicine Alcala de Henares University, 28034 Madrid, Spain
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De Barry L, Bahall V. Atypical manifestations of uterine leiomyomas - expecting the unexpected. Case Rep Womens Health 2023; 40:e00571. [PMID: 38162380 PMCID: PMC10757161 DOI: 10.1016/j.crwh.2023.e00571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Lance De Barry
- Department of Obstetrics and Gynecology, San Fernando General Hospital, South-West Regional Health Authority, Trinidad and Tobago
| | - Vishal Bahall
- Department of Obstetrics and Gynecology, San Fernando General Hospital, South-West Regional Health Authority, Trinidad and Tobago
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Maxey AP, Travis JM, McCain ML. Regulation of oxytocin-induced calcium transients and gene expression in engineered myometrial tissues by tissue architecture and matrix rigidity. Curr Res Physiol 2023; 6:100108. [PMID: 38107790 PMCID: PMC10724203 DOI: 10.1016/j.crphys.2023.100108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/21/2023] [Accepted: 09/20/2023] [Indexed: 12/19/2023] Open
Abstract
The uterus is susceptible to benign tumors known as fibroids, which have been associated with many pregnancy complications, including preterm labor. However, the impact of fibrotic tissue remodeling on the physiology of the myometrium, the smooth muscle layer of the uterus, is poorly understood, in large part due to a lack of model systems. In this study, we engineered healthy-like and fibrotic-like myometrium by culturing human myometrial smooth muscle cells on polyacrylamide hydrogels micropatterned with fibronectin to independently tune matrix rigidity and tissue alignment, respectively. We then evaluated calcium transients in response to oxytocin stimulation. Isotropic myometrial tissues on stiff substrates (representing fibrotic myometrium) had shorter calcium transients due to shorter decay time compared to aligned myometrial tissues on soft substrates (representing healthy myometrium). Calcium transients in aligned tissues had longer response times and longer decay times than isotropic tissues, irrespective of substrate stiffness. The amplitude of calcium transients was also higher on soft substrates compared to stiff substrates, irrespective of tissue alignment. We also performed RNA sequencing to detect differentially expressed genes between healthy- and fibrotic-like tissues, which revealed that a bitter taste receptor shown to induce smooth muscle relaxation, TAS2R31, was down-regulated in fibrotic-like tissues. Finally, we measured oxytocin-induced calcium transients in response to pre-treatment with progesterone, caffeine, thrombin, and nifedipine to demonstrate applications for our model system in drug screening. Both progesterone and caffeine caused a decrease in calcium transient duration, as expected, while thrombin and nifedipine had less impact. Collectively, our engineered model of the myometrium enables new insights into myometrial mechanobiology and can be extended to identify or screen novel drug targets.
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Affiliation(s)
- Antonina P. Maxey
- Laboratory for Living Systems Engineering, Alfred E. Mann Department of Biomedical Engineering, USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Jaya M. Travis
- Laboratory for Living Systems Engineering, Alfred E. Mann Department of Biomedical Engineering, USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
| | - Megan L. McCain
- Laboratory for Living Systems Engineering, Alfred E. Mann Department of Biomedical Engineering, USC Viterbi School of Engineering, University of Southern California, Los Angeles, CA, USA
- Department of Stem Cell Biology and Regenerative Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
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Kinariwala DJ, Khaja MS, McCann S, Sheeran D, Park AW, Wilkins LR, Matsumoto AH, Redick DL. Pre-operative uterine artery embolization before hysterectomy or myomectomy: a single-center review of 53 patients. Clin Imaging 2023; 101:121-125. [PMID: 37329639 DOI: 10.1016/j.clinimag.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
PURPOSE To assess outcomes of planned pre-operative uterine artery embolization (UAE) in patients with uterine fibroids at high risk for bleeding prior to hysterectomy or myomectomy. MATERIALS & METHODS A retrospective review of 53 consecutive patients who underwent planned UAE followed by surgery from 2004 to 2019 was performed in a subset of patients deemed high risk for bleeding by the referring surgeon due to bulky fibroids and/or adhesions. Characteristics of the largest fibroid, total number of fibroids, embolic agents, estimated blood loss (EBL), complications, and other factors were collected. RESULTS 53 patients (mean age = 41) had an elective UAE prior to a hysterectomy 24 (45%) or myomectomy 29 (55%). Median interval between UAE & surgery was 21.6 h (range 1.75 h-57 days). Of the myomectomies, 13 (45%) were open, 15 (52%) hysteroscopic and 1 laparoscopic. Mean number of fibroids/patient was 4.1 (SD 1.3), mean fibroid volume was 328 cm3 (range 11-741), and the mean fibroid diameter in longest dimension was 7.4 cm (range 3.2-15). Mean EBL was 90 (SD 99.5 mL). Three (10%) myomectomy patients required blood transfusion. All hysterectomies were via a laparotomy. Mean fibroid volume was 1699 cm3 (range 93-9099 cm3) with a mean maximum diameter of 16.2 cm (range 6.5-29.6) and an average of 2.4 (SD 1.7) fibroids. Mean EBL was 352 (SD 220 mL). Four (17%) hysterectomy patients required an intra- or post-operative blood transfusion. At a mean 1-year follow-up (range 1 month-14 years), 70% of UAE-myomectomy patients and 74% of UAE-hysterectomy patients reported symptom resolution. Three (6%) patients were readmitted: one for osteodiscitis, one wound dehiscence, and one for an infected retained fibroid after myomectomy. CONCLUSION Planned pre-operative UAE resulted in intraoperative blood loss similar to "all-comer" myomectomy and hysterectomy patients in the literature. Further studies may elucidate which patients would be the best candidates for this staged treatment paradigm.
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Affiliation(s)
- Dhara J Kinariwala
- Department of Radiology and Medical Imaging, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America
| | - Minhaj S Khaja
- Department of Radiology and Medical Imaging, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America.
| | - Sara McCann
- Department of Radiology and Medical Imaging, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America
| | - Daniel Sheeran
- Department of Radiology and Medical Imaging, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America
| | - Auh Whan Park
- Department of Radiology and Medical Imaging, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America
| | - Luke R Wilkins
- Department of Radiology and Medical Imaging, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America
| | - Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America
| | - Dana L Redick
- Department of Obstetrics and Gynecology, University of Virginia Health, 1215 Lee St, Charlottesville, VA 22903, United States of America
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Hosein S, Elias S, Boodram L, Bahall V, De Barry L. A subserosal uterine leiomyoma complicated with intra-abdominal haemorrhage: A case report. Case Rep Womens Health 2023; 39:e00549. [PMID: 37781450 PMCID: PMC10539634 DOI: 10.1016/j.crwh.2023.e00549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/21/2023] [Accepted: 09/22/2023] [Indexed: 10/03/2023] Open
Abstract
Uterine leiomyomas, or fibroids, are the most common benign tumours of the female genital tract. Although uterine fibroids are commonly associated with menorrhagia, dysmenorrhea, symptomatic anaemia, urinary or bowel symptoms and infertility, intra-abdominal haemorrhage is an exceedingly rare complication. Often, the diagnosis is poorly recognizable based on the patient's clinical presentation and alternative diagnoses such as ruptured ectopic pregnancy, ruptured ovarian cyst or perforated viscus are frequently considered. Herein, we describe a case of a 50-year-old perimenopausal woman who presented with acute, lower abdominal pain, evolving anaemia, hypovolaemic shock and haemoperitoneum with no discernable source. Emergency exploratory laparotomy confirmed the source of massive haemoperitoneum arising from a ruptured blood vessel supplying a large subserosal uterine leiomyoma and the patient subsequently underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Given the paucity of publications on this clinical entity, the aim of this report is to highlight a rare complication of uterine leiomyomas, its pathophysiological spectrum and its relevance to emergency physicians, general surgeons and gynaecologists.
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Affiliation(s)
- Shivon Hosein
- Department of Obstetrics and Gynaecology, San Fernando General Hospital, South-West Regional Health Authority, Trinidad and Tobago
| | - Sarah Elias
- Department of Obstetrics and Gynaecology, San Fernando General Hospital, South-West Regional Health Authority, Trinidad and Tobago
| | - Lorinda Boodram
- Department of Obstetrics and Gynaecology, San Fernando General Hospital, South-West Regional Health Authority, Trinidad and Tobago
| | - Vishal Bahall
- Department of Obstetrics and Gynaecology, San Fernando General Hospital, South-West Regional Health Authority, Trinidad and Tobago
| | - Lance De Barry
- Department of Obstetrics and Gynaecology, San Fernando General Hospital, South-West Regional Health Authority, Trinidad and Tobago
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Enazy SA, Kirschen GW, Vincent K, Yang J, Saada J, Shah M, Oberhauser AF, Bujalowski PJ, Motamedi M, Salama SA, Kilic G, Rytting E, Borahay MA. PEGylated Polymeric Nanoparticles Loaded with 2-Methoxyestradiol for the Treatment of Uterine Leiomyoma in a Patient-Derived Xenograft Mouse Model. J Pharm Sci 2023; 112:2552-2560. [PMID: 37482124 PMCID: PMC10529399 DOI: 10.1016/j.xphs.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 07/25/2023]
Abstract
Leiomyomas, the most common benign neoplasms of the female reproductive tract, currently have limited medical treatment options. Drugs targeting estrogen/progesterone signaling are used, but side effects and limited efficacy in many cases are major limitation of their clinical use. Previous studies from our laboratory and others demonstrated that 2-methoxyestradiol (2-ME) is promising treatment for uterine fibroids. However, its poor bioavailability and rapid degradation hinder its development for clinical use. The objective of this study is to evaluate the in vivo effect of biodegradable and biocompatible 2-ME-loaded polymeric nanoparticles in a patient-derived leiomyoma xenograft mouse model. PEGylated poly(lactide-co-glycolide) (PEG-PLGA) nanoparticles loaded with 2-ME were prepared by nanoprecipitation. Female 6-week age immunodeficient NOG (NOD/Shi-scid/IL-2Rγnull) mice were used. Estrogen-progesterone pellets were implanted subcutaneously. Five days later, patient-derived human fibroid tumors were xenografted bilaterally subcutaneously. Engrafted mice were treated with 2-ME-loaded or blank (control) PEGylated nanoparticles. Nanoparticles were injected intraperitoneally and after 28 days of treatment, tumor volume was measured by caliper following hair removal, and tumors were removed and weighed. Up to 99.1% encapsulation efficiency was achieved, and the in vitro release profile showed minimal burst release, thus confirming the high encapsulation efficiency. In vivo administration of the 2-ME-loaded nanoparticles led to 51% growth inhibition of xenografted tumors compared to controls (P < 0.01). Thus, 2-ME-loaded nanoparticles may represent a novel approach for the treatment of uterine fibroids.
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Affiliation(s)
- Sanaalarab Al Enazy
- Department of Pharmacology & Toxicology, University of Texas Medical Branch, Galveston, TX, USA; Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory W Kirschen
- Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - Kathleen Vincent
- Center for Biomedical Engineering, University of Texas Medical Branch, Galveston, TX, USA; Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jinping Yang
- Center for Biomedical Engineering, University of Texas Medical Branch, Galveston, TX, USA
| | - Jamal Saada
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Mansi Shah
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Andres F Oberhauser
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX, USA
| | - Paul J Bujalowski
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX, USA
| | - Massoud Motamedi
- Center for Biomedical Engineering, University of Texas Medical Branch, Galveston, TX, USA
| | - Salama A Salama
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al-Azhar University, Cairo, Egypt
| | - Gokhan Kilic
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Erik Rytting
- Department of Pharmacology & Toxicology, University of Texas Medical Branch, Galveston, TX, USA; Center for Biomedical Engineering, University of Texas Medical Branch, Galveston, TX, USA; Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX, USA
| | - Mostafa A Borahay
- Department of Gynecology & Obstetrics, Johns Hopkins University, Baltimore, MD, USA.
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10
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Saleem HA, Albalwi N, Ba'Abbad L. Uterine rupture in a term pregnancy after a previous uterine artery embolization to manage a large fibroid. A case report. Case Rep Womens Health 2023; 39:e00551. [PMID: 37829161 PMCID: PMC10565681 DOI: 10.1016/j.crwh.2023.e00551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023] Open
Abstract
Uterine artery embolization (UAE) is an effective minimally invasive alternative to surgery for the treatment of symptomatic uterine fibroids. Uterine rupture is an obstetrical emergency that requires early diagnosis and prompt management to improve perinatal and maternal outcomes. A 33-year-old woman at 37 weeks of gestation who had had previous two uncomplicated vaginal deliveries at term presented with abdominal pain and rupture of membranes. The patient had undergone UAE for the management of a large anterior wall uterine fibroid three years prior to conception. Vaginal examination revealed cord prolapse and ultrasound showed negative fetal heart. Intrauterine fetal demise with cord prolapse was diagnosed. After admission the patient developed vaginal bleeding and features of hypovolemic shock. Urgent laparotomy revealed a ruptured uterus with a large hemoperitoneum and dead fetus in the abdominal cavity. Obstetricians should be attentive to the possibility of a spontaneous uterine rupture in pregnant women who have previously undergone UAE for the management of a uterine fibroid.
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Affiliation(s)
- Heba Abu Saleem
- Department of Obstetrics and Gynaecology, King Abdullah Bin Abdulaziz University Hospital, Saudi Arabia
| | - Nouf Albalwi
- Department of Obstetrics and Gynaecology, King Abdullah Bin Abdulaziz University Hospital, Saudi Arabia
| | - Lina Ba'Abbad
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Princess Nourah Bint Abdulrahman University, Saudi Arabia
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11
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Barahmeh S, Shrateh ON, Jobran AWM, Hamarsheh L, Tanib I, Alwahsh MJ. Rare clinical entity of huge leiomyoma uteri in a 17-year-old adolescent managed with a fertility-sparing procedure: Case report and literature review. Int J Surg Case Rep 2023; 107:108367. [PMID: 37271023 DOI: 10.1016/j.ijscr.2023.108367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/26/2023] [Accepted: 05/26/2023] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The most frequent benign uterine tumor is uterine fibroids. Approximately, 20 to 30 % of women between the ages of 30 and 50 have them. Teenagers do, however, rarely experience them; the prevalence is less than 1 % in general population. CASE PRESENTATION We present a 17-year-old nulliparous female who was admitted to the hospital due to gradually increasing abdominopelvic pain. Transabdominal pelvic ultrasound showed massive uterine enlargement, with a heterogenous structure within the fundus measuring 9.8 cm in diameter. Pelvic MRI revealed an enlarged uterus with a heterogeneous complex mass measuring 10.78 cm by 8 cm that seemed to be compressing but was not attached to the endometrium The findings from the radiology review were concerning for leiomyoma. Intraoperative findings showed a 13-cm anterior intramural mass with normally appearing fallopian tubes and ovaries bilaterally. Resection of the mass was done, and the entire specimen was sent to pathology which confirmed the diagnosis of leiomyoma. DISCUSSION Occurrence of uterine fibroids in the young and adolescent age is extremely rare with an estimated prevalence of less than 1 %. Leiomyosarcoma is a less frequent diagnosis to take into account, but it can be identified histologically. Therefore, a myomectomy that preserves fertility enables a diagnostic chance to rule out a probable cancer. CONCLUSION When young women present with steadily worsening abdominopelvic discomfort, it is crucial to include leiomyomas in the differential diagnosis despite the rarity of leiomyomas in adolescents.
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Affiliation(s)
- Samer Barahmeh
- Department of Obstetrics and Gynecology, Al-Istishari Arab Hospital, Ramallah, Palestine; Faculty of Medicine, Al-Quds University, Jerusalem, Palestine.
| | - Oadi N Shrateh
- Faculty of Medicine, Al-Quds University, Jerusalem, Palestine.
| | | | - Lyudmila Hamarsheh
- Department of Obstetrics and Gynecology, Al-Istishari Arab Hospital, Ramallah, Palestine.
| | - Iyas Tanib
- Department of Obstetrics and Gynecology, Al-Istishari Arab Hospital, Ramallah, Palestine
| | - Mohammad J Alwahsh
- Department of Obstetrics and Gynecology, Al-Istishari Arab Hospital, Ramallah, Palestine
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12
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Whitaker LH, Middleton LJ, Daniels JP, Williams AR, Priest L, Odedra S, Cheed V, Stubbs CE, Clark TJ, Lumsden MA, Hapangama DK, Bhattacharya S, Smith PP, Nicholls EP, Roberts N, Semple SI, Saraswat L, Walker J, Chodankar RR, Critchley HO. Ulipristal acetate versus levonorgestrel-releasing intrauterine system for heavy menstrual bleeding (UCON): a randomised controlled phase III trial. EClinicalMedicine 2023; 60:101995. [PMID: 37251622 PMCID: PMC10209678 DOI: 10.1016/j.eclinm.2023.101995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/31/2023] Open
Abstract
Background Heavy menstrual bleeding affects one in four women and negatively impacts quality of life. Ulipristal acetate is prescribed to treat symptoms associated with uterine fibroids. We compared the effectiveness of ulipristal acetate and the levonorgestrel-releasing intrauterine system at reducing the burden of heavy menstrual bleeding, irrespective of the presence of fibroids. Methods This randomised, open-label, parallel group phase III trial enrolled women over 18 years with heavy menstrual bleeding from 10 UK hospitals. Participants were centrally randomised, in a 1:1 ratio, to either three, 12-week treatment cycles of 5 mg ulipristal acetate daily, separated by 4-week treatment-free intervals, or a levonorgestrel-releasing intrauterine system. The primary outcome, analysed by intention-to-treat, was quality of life measured by the Menorrhagia Multi-Attribute Scale at 12 months. Secondary outcomes included menstrual bleeding and liver function. The trial is registered with ISRCTN, 20426843. Findings Between June 5th, 2015 and February 26th, 2020, 236 women were randomised, either side of a recruitment suspension due to concerns of ulipristal acetate hepatoxicity. Subsequent withdrawal of ulipristal acetate led to early cessation of recruitment but the trial continued in follow-up. The primary outcome substantially improved in both groups, and was 89, (interquartile range [IQR] 65 to 100, n = 53) and 94, (IQR 70 to 100, n = 50; adjusted odds ratio 0.55, 95% confidence interval [CI] 0.26-1.17; p = 0.12) in the ulipristal and levonorgestrel-releasing intrauterine system groups. Rates of amenorrhoea at 12 months were higher in those allocated ulipristal acetate compared to levonorgestrel-releasing intrauterine system (64% versus 25%, adjusted odds ratio 7.12, 95% CI 2.29-22.2). Other outcomes were similar between the two groups and there were no cases of endometrial malignancy or hepatotoxicity due to ulipristal acetate use. Interpretation Our findings suggested that both treatments improved quality of life. Ulipristal was more effective at inducing amenorrhoea. Ulipristal has been demonstrated to be an effective medical therapeutic option but currently its use has restrictions and requires liver function monitoring. Funding UK Medical Research Council and National Institute of Health Research EME Programme (12/206/52).
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Affiliation(s)
- Lucy H.R. Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Lee J. Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jane P. Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lee Priest
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Smita Odedra
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Clive E. Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Mary-Ann Lumsden
- Reproductive & Maternal Medicine, University of Glasgow, Glasgow, UK
| | - Dharani K. Hapangama
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Paul P. Smith
- Birmingham Women's and Children's Hospital, Birmingham, UK
| | | | - Neil Roberts
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Scott I. Semple
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Jane Walker
- Department of Clinical Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rohan R. Chodankar
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | | | - UCON Collaborative
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
- Division of Pathology, University of Edinburgh, Edinburgh, UK
- Birmingham Women's and Children's Hospital, Birmingham, UK
- Reproductive & Maternal Medicine, University of Glasgow, Glasgow, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- University of Aberdeen, Aberdeen, UK
- Adcal H.R. Consultancy, UK (PPI representative)
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Clinical Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
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13
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Mitro SD, Sundaram R, Chen Z, Peddada S, Buck Louis GM, Zhang C, Grewal J, Gleason JL, Sciscione AC, Grantz KL. Leiomyomata, neonatal anthropometry, and pregnancy outcomes in singleton pregnancies. Ann Epidemiol 2023; 80:43-52. [PMID: 36822279 PMCID: PMC10040437 DOI: 10.1016/j.annepidem.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/05/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE To investigate the relationship of fibroids in pregnancy, preterm birth, and neonatal anthropometry. METHODS Pregnant women (n = 2578) in the National Institute of Child Health and Human Development Fetal Growth Studies-Singletons cohort had up to six ultrasounds across pregnancy. Sonographers recorded fibroid number and volume of the three largest fibroids. Trained personnel measured neonatal anthropometry. Linear and logistic regression compared neonatal anthropometry and pregnancy outcomes among pregnancies with versus without fibroids. Causal mediation analysis evaluated preterm birth as a mediator. RESULTS Average birthweight did not differ by fibroid status. However, compared with pregnancies without fibroids, neonates from pregnancies with single fibroids had 0.3- (95% confidence interval [CI], 0.0, 0.5) cm larger head circumferences; those with multiple fibroids had 0.3- (95% CI, 0.0, 0.6) cm larger arm circumferences; and those with small fibroid volume had 0.7- (95% CI, 0.3, 1.2) cm larger head, 0.4- (95% CI, 0.0, 0.8) cm larger arm, and 0.7- (95% CI, 0.1, 1.3) cm larger thigh circumferences. Presence versus absence of fibroids was associated with 1.73-2.65 times higher odds of preterm birth. Differences in preterm birth did not explain fibroid-anthropometry results. CONCLUSIONS We found no evidence that fibroids negatively impacted fetal growth; instead, fibroids were associated with increased head, arm, and thigh circumferences. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT00912132.
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Affiliation(s)
- Susanna D Mitro
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Rajeshwari Sundaram
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Zhen Chen
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Shyamal Peddada
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Cuilin Zhang
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD; Department of Obstetrics and Gynecology, National University of Singapore Yong Loo Lin School of Medicine, Singapore
| | - Jagteshwar Grewal
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Jessica L Gleason
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | | | - Katherine L Grantz
- Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD.
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14
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Tal MG, Keidar R, Magnazi G, Henn O, Kim JH, Chudnoff SG, Stepp KJ. Pressure-Induced Fibroid Ischemia: First-In-Human Experience with a Novel Device for Laparoscopic Treatment of Symptomatic Uterine Fibroids. Reprod Sci 2023; 30:1366-1375. [PMID: 35941511 PMCID: PMC9360636 DOI: 10.1007/s43032-022-01033-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/04/2022] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to assess the feasibility of use of a novel uterine fibroid treatment device hypothesized to cause fibroid infarction by increasing intra-tumoral pressure. Between August 2019 and January 2020, 21 uterine fibroids were treated in 16 symptomatic pre-menopausal black women. Pelvic magnetic resonance imaging was performed before the procedure, a day after the procedure and at 1, 3, 6, and 12 months. The subjects were also followed for clinical outcomes and quality of life up to 12 months at a single investigational site. At 3 months, the mean reduction in the fibroid volume was 36.3% (P = .002). Incremental reduction in volume peaked at the end of the follow-up, at the 12-month mark (60.4%; P = .008). There were no procedures in which the users failed to perform laparoscopic pressure suturing of fibroids with the pressure-induced fibroid ischemia device. Improvement in the quality of life was evident in the Health-Related Quality of Life total, Energy/Mood, Control, and Sexual Function domains of the Uterine Fibroid Symptom and Quality of Life questionnaire at 3 months post-procedure. Unanticipated risks were not identified. Serious adverse events were not identified. The initial clinical assessment of the pressure-induced fibroid ischemia device supports feasibility of the approach and does not reveal serious safety concerns. Trial is currently being registered retrospectively (This was a feasibility study and therefore registration was not mandatory).
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Affiliation(s)
- Michael G Tal
- Division of Interventional Radiology, Hadassah Medical Center, Jerusalem, Israel.
| | - Ran Keidar
- Department of Obstetrics and Gynecology, E. Wolfson Medical Center, Holon, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Ohad Henn
- Empress Medical Ltd., Tel Aviv, Israel
| | - Jin Hee Kim
- Department of Obstetrics & Gynecology, Columbia University, New York, NY, USA
| | - Scott G Chudnoff
- Obstetrics and Gynecology, Maimonides Medical Center, New York, NY, USA
| | - Kevin J Stepp
- Atrium Health Women's Care Urogynecology and Pelvic Surgery, Atrium Health, Charlotte, NC, USA
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15
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Dokuzeylül Güngör N, Önal M, Madenli AA, Ağar M. Surgical removal of FIGO type 0 and 1 fibroids ameliorates the expression of endometrial proinflammatory transcription factors and receptivity modulators. Fertil Steril 2023; 119:504-513. [PMID: 36473610 DOI: 10.1016/j.fertnstert.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To reveal whether hysteroscopic removal of the International Federation of Gynecology and Obstetrics (FIGO) types 0 and 1 fibroids makes any changes in the expression of homeobox genes (HOXA10, HOXA11), leukemia inhibitory factor, and nuclear factor-kappa B (NF-kB). DESIGN A case-control study. SETTING University-based in vitro fertilisation center. PATIENT(S) This study consisted of a total of 29 participants, 21 with FIGO types 0 and 1 fibroids and 8 with normal uterine cavity without fibroids. INTERVENTION(S) Patients in FIGO types 0 and 1 fibroids group underwent hysteroscopic myomectomy. The patients in the control group underwent laparoscopic tubal ligation. Endometrial cells were collected by flushing method from all participants before and 3 months after myomectomy. Real-time polymerase chain reaction was used to detect HOXA10, HOXA11, and LIF mRNA expressions in endometrial flushing samples. The relative expressions of homeobox and LIF mRNA were calculated with comparative ΔCt method. Endometrial NF-kB concentration was measured quantitatively by enzyme-linked immunosorbent assay. MAIN OUTCOME MEASURE(S) To compare endometrial HOXA10, HOXA11, and LIF mRNA expressions as well as endometrial NF-kB concentration before and after myomectomy. RESULT(S) Premyomectomy NF-kB levels of type 0 (4.22 ± 1.02 ng/mL) and type 1 fibroid (6.44 ± 2.30 ng/mL) were significantly higher than the values of control group (0.54 ± 0.10 ng/mL). Surgical removal of type 0 and 1 fibroids resulted in a significant decrease in endometrial NF-kB levels (1.33 ± 0.02 ng/mL vs 1.65 ± 0.27 ng/mL, respectively). In type 0 fibroid group, after myomectomy, there was a 11.1-fold increase in HOXA10 mRNA, 4.23-fold in HOXA11 mRNA, and 7.63-fold in LIF mRNA. In the type 1 fibroid group, after myomectomy, there was a 16.3-fold increase in HOXA10 mRNA, 8.34-fold in HOXA11 mRNA, and 9.38-fold in LIF mRNA. A nonsignificant change was detected in homeobox and LIF mRNA after tubal sterilization. A negative and significant correlation was found between endometrial NF-kB and HOXA10 (r=-0.67), HOXA11 (r=-0.71) and LIF (r=-0.54). CONCLUSION(S) High proinflammatory NF-kB concentration and low homeobox and LIF mRNA expressions were detected in the presence of type 0 or 1 fibroids that returned to normal values after hysteroscopic myomectomy.
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Affiliation(s)
- Nur Dokuzeylül Güngör
- Department of Obstetrics and Gynecology, Bahcesehir University Goztepe Medicalpark Hospital, Istanbul, Turkey.
| | - Murat Önal
- Department of Obstetrics and Gynecology, Gynolife Hospital, Nicosia, Cyprus
| | - Asena Ayar Madenli
- Department of Obstetrics and Gynecology, Liv Hospital Vadistanbul, Istanbul, Turkey
| | - Mehmet Ağar
- Obstetrics and Gynecology, Private Office, Sanliurfa, Turkey
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16
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Wu H, Singh B, Yen TT, Maher J, Datta S, Chaves K, Lau BD, Frank S, Simpson K, Patzkowsky K, Wang K. Utilization and cost of cell salvage in minimally invasive myomectomy. Eur J Obstet Gynecol Reprod Biol 2023; 280:179-183. [PMID: 36512958 DOI: 10.1016/j.ejogrb.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/29/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To assess the utilization and cost of intraoperative cell salvage (ICS) in minimally invasive myomectomy. STUDY DESIGN Retrospective cohort study of patients who underwent minimally invasive myomectomy at a quaternary care academic hospital. Patients were classified into: ICS setup vs no ICS setup, ICS setup with reinfusion vs ICS setup without reinfusion. RESULTS Of 382 patients who underwent minimally invasive myomectomy, 67 (17.5 %) had ICS setup, 30 (44.8 %) of those patients reinfused. Median volume of reinfusion per patient was 300 mL (range 125-1000 mL). Patients who ultimately underwent ICS reinfusion, compared to those with ICS setup only, had significantly larger mean maximum fibroid size (9.8 cm vs 8.0 cm, p = 0.02), higher median total specimen weight (367 vs 304 g, p = 0.03), higher median estimated blood loss (575 vs 300 mL, p < 0.0001), longer mean operative time (261 vs 215 min, p = 0.04). No perioperative complications were associated with ICS. Higher costs are associated with universal use or complete lack of ICS; lowest cost is associated with ICS setup only for those ultimately reinfused. CONCLUSION ICS might reduce requirements for allogeneic blood transfusions in patients undergoing minimally invasive myomectomy, and may contribute to cost savings. Uterine and maximum fibroid sizes are possible preoperative indicators for patients who require cell salvage reinfusion.
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Affiliation(s)
- Harold Wu
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Bhuchitra Singh
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
| | - Ting-Tai Yen
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Jacqueline Maher
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Shreetoma Datta
- Division of Reproductive Sciences and Women's Health Research, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Katherine Chaves
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Brandyn D Lau
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore MD, United States of America
| | - Steven Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Khara Simpson
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Kristin Patzkowsky
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Karen Wang
- Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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17
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Garg P, Bansal R. Neglected case of a huge leiomyoma in an elderly postmenopausal woman: a case report. J Med Case Rep 2022; 16:485. [PMID: 36578085 PMCID: PMC9798543 DOI: 10.1186/s13256-022-03705-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 12/02/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Fibroids are benign tumors of the female reproductive tract originating from the myometrial smooth muscle cells. They are a frequent occurrence in women of childbearing age but their incidence is rare after menopause. In addition, there is a remote possibility of malignant transformation to leiomyosarcoma in less than 1% of cases. CASE PRESENTATION We hereby report a case of large fibroid in a postmenopausal Indian female with rapid growth, raising the suspicion of malignant transformation into leiomyosarcoma. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathology report confirmed it to be benign leiomyoma without any evidence of neoplasia. CONCLUSION Sudden enlargement of leiomyoma in postmenopausal women should not be ignored due to possible malignant transformation and is to be dealt immediately with hysterectomy followed by histopathology.
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Affiliation(s)
- Priyanka Garg
- grid.413618.90000 0004 1767 6103Present Address: Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bathinda, Punjab 151001 India ,grid.427691.f0000 0004 1799 5307Department of Obstetrics and Gynaecology, Adesh Institute of Medical Sciences and Research, Bathinda, 151001 India
| | - Romi Bansal
- grid.427691.f0000 0004 1799 5307Department of Obstetrics and Gynaecology, Adesh Institute of Medical Sciences and Research, Bathinda, 151001 India
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18
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Otonkoski S, Sainio T, Mattila S, Blanco Sequieros R, Perheentupa A, Komar G, Joronen K. Magnetic resonance guided high intensity focused ultrasound for uterine fibroids and adenomyosis has no effect on ovarian reserve. Int J Hyperthermia 2022; 40:2154575. [PMID: 36535925 DOI: 10.1080/02656736.2022.2154575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Uterine fibroids are the most common benign tumors in healthy women. High Intensity Focused Ultrasound (HIFU) is a modern, noninvasive thermal ablation method for treating uterine fibroids. There is increasing evidence that ultrasound guided HIFU (US-HIFU) has no adverse impact on ovarian reserve but little data exists on magnetic resonance guided HIFU (MR-HIFU). There are different options to estimate ovarian reserve, perhaps the most reliable being the measurement of serum Anti-Müllerian hormone (AMH). MATERIAL AND METHODS Seventy-four (74) premenopausal women with serum AMH 0.1 ug/L or over, aged 24-48 and with fibroids or adenomyosis treated with MR-HIFU were enrolled in our study. AMH levels were analyzed before and 3 months after the MR-HIFU treatment. Correlations between AMH level changes and position of fibroids, fibroid volume, non-perfused volume ratio, and treatment energies were studied. RESULTS The median AMH level before the HIFU treatment was 1.20 (range: 0.1-7.75 ug/L) and after the treatment 1.23 (range: 0.1-8.51 ug/L). No significant change was detected (p = .90). The patients were divided in three subgroups depending on the baseline AMH levels. The changes were not significant in any of the subgroups. Neither did the location of the treated fibroid affect the change of AMH levels nor the total energy used during treatment. CONCLUSIONS MR-HIFU does not compromise the ovarian reserve. Neither the location of the treated fibroid nor the total energy used during MR-HIFU had any effect on the change of AMH levels.
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Affiliation(s)
- Saara Otonkoski
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Teija Sainio
- Department of Radiology, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Finland
| | - Sami Mattila
- Department of Medical Physics, Turku University Hospital, Finland
| | - Roberto Blanco Sequieros
- University of Turku, Turku, Finland.,Department of Radiology, Turku University Hospital, Turku, Finland
| | - Antti Perheentupa
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Gaber Komar
- University of Turku, Turku, Finland.,Department of Radiology, Turku University Hospital, Turku, Finland
| | - Kirsi Joronen
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
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Piriyev E, Römer T. Delayed expulsion of a large fibroid after transcervical radiofrequency ablation: A case report. Radiol Case Rep 2022; 18:779-783. [PMID: 36589487 PMCID: PMC9794886 DOI: 10.1016/j.radcr.2022.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 11/18/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
Fibroids are the most common type of benign uterine tumor, which occur up to 68.6% of women. Hypermenorrhea is the most common symptom with a general prevalence of 40%-54%, followed by dysmenorrhea and low abdominal pain. Transcervical fibroids ablation was developed as a minimally invasive, incisionless treatment of fibroids in a short time. This method is safe and effective with an excellent record of safety. We present the case of a 40-year-old woman, who attended in our fibroid excellence center. She reported severe hypermenorrhea and dysmenorrhea. Family planning was definitely completed. Using vaginal ultrasonography a FIGO 2-5 fibroid of 5 cm in diameter was detected. Different treatment options were discussed: medical treatment, laparoscopic fibroidectomy, hysterectomy, and transcervical radiofrequency ablation with Sonata System. Because of advantages of transcervical radiofrequency ablation (minimal invasive treatment without incision, effectivity of method, short surgical time) the patient decided on this method. Three months later, the patient came to the first follow up. She reported a significant improvement of hypermenorrhea. A vaginal ultrasonography was carried out. The fibroid changed its position from FIGO 2-5 to FIGO 2. The patient was very satisfied with the result. After 2 months, she attended in our department again because of severe clear vaginal discharge. She had no bleeding, no pain as well as no fever. We examined her immediately. A fibroid expulsion was detected. The fibroid was removed vaginally. There was no severe bleeding during the operation and the fibroid could be removed completely. The surgery time was 25 minutes.
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Affiliation(s)
- Elvin Piriyev
- University Witten-Herdecke, Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Weyertal 76, 50931 Cologne, Germany
- Corresponding author.
| | - Thomas Römer
- Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Cologne, Germany
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Chandrasekaran S, Antakia R, Olugbemi M. Buttock necrosis following uterine artery embolization: A case report. Int J Surg Case Rep 2023; 102:107833. [PMID: 36495754 DOI: 10.1016/j.ijscr.2022.107833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/30/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Fibroid is a very common benign tumor of the uterus for which uterine artery embolization is one of the treatment modalities of choice. Uterine artery embolization (UAE) is a minimally invasive procedure used in the management of fibroids, nowadays mostly performed by interventional radiologists. A rare complication of the procedure is buttock necrosis which has been observed in this case. If not identified at an early stage, it may result in extensive damage to a large surface area of the skin hence this case report is of clinical relevance as it is essential to be aware of the complications of UAE and be cautious. CASE PRESENTATION Our report is regarding a 37-year-old female who presented to the emergency department with a gradually increasing excruciatingly painful lesion on the left buttock 12 days after undergoing a uterine artery embolization. Examination revealed a necrotic lesion involving 40 % surface area of the left buttock. CLINICAL DISCUSSION There are a few other such cases reported in literature. All these cases, including ours, prove that buttock necrosis is an established complication which is highly possible following uterine artery embolization. This complication is likely due to reflux of embolic material into gluteal artery. CONCLUSION This case warranted extensive debridement and plastic surgery referral for skin grafting. Although a rare scenario, being a dangerous and distressful one for patients, ability to recognize this complication at an early stage will aid in the management and mental well-being of the patient.
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Mahalingam M, Hu M, Schointuch M, Szychowski JM, Harper L, Owen J, Sinkey R. Uterine myomas: effect of prior myomectomy on pregnancy outcomes. J Matern Fetal Neonatal Med 2022; 35:8492-8497. [PMID: 34615420 PMCID: PMC10961099 DOI: 10.1080/14767058.2021.1984424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Reproductive aged women with fibroids must weigh the risks and benefits of preconception myomectomy. Women with fibroids may have higher rates of fetal growth restriction (FGR) and stillbirth; however, there is a paucity of data on the impact of myomectomy on pregnancy outcomes. We compared perinatal outcomes in women with prior myomectomy versus those with no prior myomectomy and at least one fibroid ≥ 5 cm. METHODS Retrospective cohort study of women at a single center who delivered between 2008 and 2017 with a viable intrauterine pregnancy at initial ultrasound scan and either prior myomectomy, or, in the no-myomectomy cohort, at least one fibroid ≥ 5 cm on a prenatal scan performed at < 21 weeks' gestation (wga). Pregnancies complicated by major congenital anomalies were excluded. Primary outcome was preterm birth (PTB) < 37wga. Secondary outcomes included rates of spontaneous loss, cesarean delivery (CD), abnormal placentation, malpresentation, FGR, birthweight, birthweight percentile, estimated blood loss (EBL), blood transfusion, and neonatal survival to discharge. RESULTS A total of 290 women met inclusion criteria: 70 had a prior myomectomy, 220 women had ≥1 fibroid ≥5cm. Women with prior myomectomy were older, more likely to have private insurance, and more likely used artificial reproductive technology to conceive; 20% with prior myomectomy still had at least one ≥ 5 cm myoma on their obstetric scan. Rates of spontaneous loss were lower in the prior myomectomy group (1.4% vs 7.3%; p = .08). Of the 273 pregnancies continuing beyond 20 weeks, women with prior myomectomy had significantly more PTBs (35% vs. 21%, p = .02) and significantly different primary birth indications (p < .0001). However, after controlling for late preterm, prelabor cesareans recommended by providers in the myomectomy cohort, the difference in PTB rates was not significant (p = .13). The myomectomy group had more CDs (88% vs. 53%, p < .0001), higher EBL (1250 mL vs. 811 mL, p = .04), and a trend toward more blood transfusions (16% vs 8%, p = .05). Other selected outcomes were similar, including rates of FGR. CONCLUSIONS Women with prior myomectomy had significantly more PTBs, due in part to more preterm, prelabor cesareans in the late preterm period. Otherwise, prior myomectomy did not confer appreciable obstetric or perinatal benefits, as patients had more CDs, and higher EBL. Recommendations to perform preterm prelabor cesareans in this population may explain some of the PTB disparity. The effect of prior myomectomy on early pregnancy loss and infertility requires further study.
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Affiliation(s)
- Mythreyi Mahalingam
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Muhan Hu
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Monica Schointuch
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeff M. Szychowski
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lorie Harper
- Department of Women’s Health, University of Texas at Austin, Dell Medical School, Austin, TX, USA
| | - John Owen
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel Sinkey
- Center for Women’s Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
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22
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Hacking N, Vigneswaran G, Maclean D, Bryant T, Umranikar S, Cheong Y, Modi S. The impact on Anti-Mullerian Hormone (AMH), uterine fibroid size and uterine artery patency following Uterine Fibroid Embolization (UFE) with a resorbable embolic agent. HUM FERTIL 2022; 25:881-887. [PMID: 33926340 DOI: 10.1080/14647273.2021.1920055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The effect of Uterine Fibroid Embolization on fertility and ovarian reserve remains uncertain. We assessed the impact of a new resorbable, spherical particle (Gelbead) on concentration of Anti-Mullerian (AMH) hormone, fibroid volume and uterine artery patency. This prospective cohort study recruited consecutive patients from July 2017 to June 2018. Serum AMH, fibroid and uterine volume, UFS-QOL (uterine fibroid score-quality of life) scores were measured prior to and at 1 month and/or 3 months post embolization. Twenty-four participants were enrolled (median age 44 years, uterine volume 484 cm3, initial dominant fibroid volume 167 cm3). One patient was lost to follow-up. AMH (median ± SD) immediately prior to embolization was 3.2 ± 13.7 pmol/L. At 1-month postembolization, AMH was 4.1 ± 8.6 pmol/L and at 3 months 4.4 ± 8.6 pmol/L. We found no significant difference in AMH levels between baseline and at 1 month (p = 0.58) or baseline and 3 months (p = 0.17). The median dominant uterine fibroid volume decreased (167 to 64 cm3, p < 0.001). At 3 months post-embolization, 17/23 patients had patent uterine arteries bilaterally (73.9%). UFE with Gel-bead did not significantly affect AMH at 3 months post embolization, whilst maintaining a high rate of uterine artery patency.
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Affiliation(s)
- Nigel Hacking
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
| | - Ganesh Vigneswaran
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK.,Cancer Sciences, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, UK
| | - Drew Maclean
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
| | - Timothy Bryant
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
| | - Sameer Umranikar
- Department of Obstetrics and Gynaecology, University Hospital Southampton, Southampton, UK
| | - Ying Cheong
- Human Development and Health Faculty of Medicine, University of Southampton, Southampton, UK.,Complete Fertility Southampton, Princess Anne Hospital, Southampton, UK
| | - Sachin Modi
- Department of Interventional Radiology, University Hospital Southampton, Southampton, UK
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23
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Ascher SM, Wasnik AP, Robbins JB, Adelman M, Brook OR, Feldman MK, Jones LP, Knavel Koepsel EM, Patel-Lippmann KK, Patlas MN, VanBuren W, Maturen KE. ACR Appropriateness Criteria® Fibroids. J Am Coll Radiol 2022; 19:S319-S328. [PMID: 36436959 DOI: 10.1016/j.jacr.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
Uterine fibroids (leiomyomas or myomas) are the most common neoplasm of the uterus. Though incompletely understood, fibroid etiology is multifactorial, a combination of genetic alterations and endocrine, autocrine, environmental, and other factors such as race, age, parity, and body mass index. Black women have greater than an 80% incidence of fibroids by age 50, whereas White women have an incidence approaching 70%. Fibroid symptoms are protean, and menorrhagia is most frequent. The societal economic burden of symptomatic fibroids is large, 5.9 to 34.3 billion dollars annually. There are a variety of treatment options for women with symptomatic fibroids ranging from medical therapy to hysterectomy. Myomectomy and uterine fibroid embolization are the most common uterine sparing therapies. Pelvic ultrasound (transabdominal and transvaginal) with Doppler and MRI with and without intravenous contrast are the best imaging modalities for the initial diagnosis of fibroids, the initial treatment of known fibroids, and for surveillance or posttreatment imaging. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia.
| | - Ashish P Wasnik
- Panel Vice-Chair, University of Michigan, Ann Arbor, Michigan; Director, Division of Abdominal Radiology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan
| | - Jessica B Robbins
- Panel Chair; Vice Chair, Faculty Development and Enrichment, University of Wisconsin, Madison, Wisconsin
| | - Marisa Adelman
- Technology Assessment Committee, University of Utah, Salt Lake City, Utah; American College of Obstetricians and Gynecologists
| | - Olga R Brook
- Section Chief, Abdominal Imaging; Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Lisa P Jones
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Krupa K Patel-Lippmann
- Abdominal Imaging Fellowship Director, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael N Patlas
- McMaster University, Hamilton, Ontario, Canada; Editor-in-Chief, Canadian Association of Radiologists
| | - Wendaline VanBuren
- Section Chair, Gynecological Imaging, Department of Radiology Mayo Clinic, Rochester, Minnesota; Chair, Endometriosis Disease-Focused Panel, Society of Abdominal Radiology
| | - Katherine E Maturen
- Specialty Chair; Associate Chair, Ambulatory Care and Strategy, University of Michigan, Ann Arbor, Michigan
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24
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Han Y, Yao R, Zhang Y, Yang Z, Luo H, Wang X, Du A, Zhang Y, Zhu Y. Hysteroscopic resection of type 3 fibroids could improve the pregnancy outcomes in infertile women: a case-control study. BMC Pregnancy Childbirth 2022; 22:522. [PMID: 35764945 PMCID: PMC9241258 DOI: 10.1186/s12884-022-04828-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/07/2022] [Indexed: 11/10/2022] Open
Abstract
Background Type 3 fibroids are a special subtype of intramural fibroids that are likely to affect the pregnancy outcomes of assisted reproductive techniques. Hysteroscopic resection is a treatment for type 3 fibroids, but there has few study of its efficacy to date. In this study we evaluated the effect of hysteroscopic resection of type 3 fibroids on the pregnancy outcomes in infertile women. Methods This retrospective case–control study was conducted from January 1, 2014 to June 30, 2021. Patients who underwent IVF-ICSI in our unit were divided into a type 3 fibroid group and a hysteroscopic myomectomy group. The inclusion criteria for the type 3 fibroid group and the hysteroscopic myomectomy group were as follows: 1) age ≤ 40 years; 2) fibroid diameter or total fibroid diameter > 2.0 cm. The following exclusion criteria were used: 1) oocyte donor treatment cycles and 2) presence of chromosomal abnormalities; 3) history of other uterine surgery; 4) presence of intracavitary lesions, including submucosal fibroids; 5) single fibroid > 5.0 cm; 6) cervical fibroids; 7) unclear ultrasound description of fibroids; 8) preimplantation genetic testing was performed and 9) congenital or acquired uterine malformations. The control group in our study was selected from patients who were treated with IVF only because of fallopian tube factors. According to the age of the type 3 fibroid group and hysteroscopic myomectomy group, random sampling was carried out in the patients between 25 and 47 years of age to determine a control group. The outcomes measured included the average transfer times to live birth, cumulative clinical pregnancy rate, and cumulative live birth rate. Results A total of 302 cycles were enrolled in our study, including 125 cycles with type 3 fibroids, 122 cycles with hysteroscopic myomectomy, and 139 cycles of control patients. The average transfer times to live birth were significantly higher in the type 3 fibroid group than in the other two groups. The frequency of cumulative live births in the type 3 fibroid group was significantly lower than that in the control group. Compared with the control group, the hysteroscopic myomectomy patients had no statistically significant differences in the cumulative clinical pregnancy rate and cumulative live birth rate. Conclusions Type 3 fibroids significantly reduced the cumulative live birth rate of IVF patients. Ultrasound-guided hysteroscopic myomectomy can be used as a treatment for type 3 fibroids and could improve the pregnancy outcomes in infertile women.
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Affiliation(s)
- Ying Han
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China
| | - Ruqiang Yao
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China
| | - Yinfeng Zhang
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China
| | - Zexin Yang
- Tianjin Medical University, Tianjin, 300070, China
| | - Haining Luo
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China
| | - XinYan Wang
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China
| | - Aijun Du
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China
| | - Yunshan Zhang
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China.
| | - Yingjun Zhu
- Tianjin Key Laboratory of Human Development and Reproductive Regulation, Tianjin Central Hospital of Gynaecology Obstetrics, No 156 Sanma Road, Nankai District, Tianjin, 300100, China.
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25
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Lin E, Sendukas E, Kho KA. Post-Operative Uterine Necrosis and Peritonitis Following Laparoscopic Radiofrequency Fibroid Ablation. J Minim Invasive Gynecol 2022; 29:1123-1124. [PMID: 35691549 DOI: 10.1016/j.jmig.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Emily Lin
- Division of Gynecology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas (all authors).
| | - Emily Sendukas
- Division of Gynecology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas (all authors)
| | - Kimberly A Kho
- Division of Gynecology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas (all authors)
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26
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Chuang TD, Quintanilla D, Boos D, Khorram O. Differential Expression of Super-Enhancer-Associated Long Non-coding RNAs in Uterine Leiomyomas. Reprod Sci 2022; 29:2960-2976. [PMID: 35641855 PMCID: PMC9537225 DOI: 10.1007/s43032-022-00981-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/18/2022] [Indexed: 11/18/2022]
Abstract
Super-enhancer-associated long non-coding RNAs (SE-lncRNAs) are a specific set of lncRNAs transcribed from super-enhancer (SE) genomic regions. Recent studies have revealed that SE-lncRNAs play essential roles in tumorigenesis through the regulation of oncogenes. The objective of this study was to elucidate the expression profile of SE-lncRNAs with concurrent assessment of associated mRNAs in leiomyomas and paired myometrium. Arraystar SE-lncRNAs arrays were used to systematically profile the differentially expressed SE-lncRNAs along with the corresponding SE-regulated protein coding genes in eight leiomyomas and paired myometrium. The analysis indicated 7680 SE-lncRNAs were expressed, of which 721 SE-lncRNAs were overexpressed, while 247 SE-lncRNAs were underexpressed by 1.5-fold or greater in leiomyoma. Thirteen novel SE-lncRNAs and their corresponding protein coding genes were selected, and their expression was confirmed in eighty-one paired leiomyoma tissues by quantitative real-time PCR. The thirteen pairs of SE-lncRNAs and their corresponding protein coding genes included RP11-353N14.2/CBX4, SOCS2-AS1/SOCS2, RP1-170O19.14/HOXA11, CASC15/PRL, EGFLAM-AS1/EGFLAM, RP11-225H22/NEURL1, RP5-1086K13.1/CD58, AC092839.3/SPTBN1, RP11-69I8.3/CTGF, TM4SF1-AS1/TM4SF1, RP11-373D23/FOSL2, RP11-399K21.11/COMTD1, and CTB-113P19.1/SPARC. Among these SE-lncRNAs, the expression of SOCS2-AS1/SOCS2, RP11-353N14.2/CBX4, RP1-170O19.14/HOXA11, and RP11-225H22/NEURL1 was significantly higher in African Americans as compared with Caucasians. The expression of RP11-353N14.2/CBX4, SOCS2-AS1/SOCS2, CASC15/PRL, and CTB-113P19.1/SPARC was significantly higher in tumors with MED12-mutation-positive as compared with MED12-mutation-negative tumors. Collectively, our results indicate that the differential expression of SE in leiomyomas is another mechanism contributing to dysregulation of protein coding genes in leiomyomas and that race and MED12 mutation can influence the expression of a select group of SE.
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Affiliation(s)
- Tsai-Der Chuang
- Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center and The Lundquist Institute, Torrance, CA, 90502, USA
| | - Derek Quintanilla
- Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center and The Lundquist Institute, Torrance, CA, 90502, USA
| | - Drake Boos
- Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center and The Lundquist Institute, Torrance, CA, 90502, USA
| | - Omid Khorram
- Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center and The Lundquist Institute, Torrance, CA, 90502, USA.
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27
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Lukies M, Clements W. Current Strategies for Prevention of Infection After Uterine Artery Embolisation. Cardiovasc Intervent Radiol 2022; 45:911-917. [PMID: 35578034 PMCID: PMC9225967 DOI: 10.1007/s00270-022-03158-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
Abstract
Uterine artery embolisation (UAE) is a safe and effective procedure for symptomatic uterine fibroids with an estimated rate of post-operative intra-uterine infection of 0.9-2.5%. While rates of infection have remained low over the past two decades, there is variation in infection prevention practices. Intra-uterine infection after UAE may occur via access site haematogenous spread or ascension of vaginal flora through the cervical canal. Although the evidence base is immature, risk factors for infection including previous pelvic infection, hydrosalpinx, endocervical incompetence, diabetes, smoking, obesity, respiratory disease, and immunosuppression should be assessed during the pre-operative consultation with the interventional radiologist to tailor a plan for minimising infection, which may include optimisation of any modifiable risk facts and prophylactic antibiotics.
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Affiliation(s)
- Matthew Lukies
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia. .,Department of Surgery, Monash University, Melbourne, VIC, Australia. .,National Trauma Research Institute, Melbourne, VIC, Australia.
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28
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Römer T, Bends R, Christoffel L, Felberbaum R, Hildebrandt T, Meinhold-Heerlein I, Mueller M, Oppelt P, Renner SP, Runnebaum IB, Schiermeier S, Piriyev E, Uhl B, Toub D. The significance of transcervical ultrasound-guided radiofrequency ablation in the treatment of symptomatic fibroids: results of an expert consensus from German-speaking countries. Arch Gynecol Obstet 2022; 306:1-6. [PMID: 35316395 DOI: 10.1007/s00404-022-06516-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Uterine fibroids are one of the most common diseases in female patients, lead mainly to bleeding disorders and lower abdominal pain, and reduce the chance of having children. In recent years we have seen a trend towards more and more pharmacotherapies and minimally invasive organ-preserving treatments. One novel and innovative procedure for an organ-preserving treatment of symptomatic uterine fibroids is the transcervical ultrasound-guided radiofrequency ablation (TRFA). TRFA has been used in Germany since 2013 and later found use in other German-speaking countries as well. There have now been more than 1200 TRFA treatments performed in Germany, Austria, and Switzerland. Experts from these three countries came together for a consensus meeting to analyze the significance of the procedure in the overall concept of the treatment of symptomatic uterine fibroids.
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Affiliation(s)
- Thomas Römer
- Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Weyertal 76, 50931, Cologne, Germany.
| | - Ralf Bends
- Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Weyertal 76, 50931, Cologne, Germany
| | | | - Ricardo Felberbaum
- Department of Obstetrics and Gynecology, Clinic of Kempten, Academic Teaching Hospital, University of Ulm, Ulm, Germany
| | - Thomas Hildebrandt
- Department of Obstetrics and Gynecology, University Hospital Erlangen-Nuremberg, Maximilianspl. 2, 91054, Erlangen, Germany
| | - Ivo Meinhold-Heerlein
- Department of Gynecology and Obstetrics, Justus Liebig University Giessen, Giessen, Germany
| | - Michael Mueller
- University Department of Gynecology, Bern University Hospital, Bern, Switzerland
| | - Peter Oppelt
- Department for Gynecology, Obstetrics and Gynecological Endocrinology, Johannes Kepler University Linz, Linz, Austria
| | - Stefan P Renner
- Department of Obstetrics and Gynecology, Sindelfingen-Boeblingen Clinic, Boeblingen, Germany
| | - Ingo B Runnebaum
- Department of Gynecology and Reproduction Medicine, Jena University Hospital, 07747, Jena, Germany
| | - Sven Schiermeier
- Department of Obstetrics and Gynecology, University Witten-Herdecke, Marien-Hospital, Witten Marienplatz, 258452, Witten, Germany
| | - Elvin Piriyev
- Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Weyertal 76, 50931, Cologne, Germany
- Department of Obstetrics and Gynecology, University Witten-Herdecke, Marien-Hospital, Witten Marienplatz, 258452, Witten, Germany
| | - Bernhard Uhl
- Department of Obstetrics and Gynecology, Wesel Evangelical Hospital, Wesel, Germany
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Diakosavvas M, Angelou K, Fasoulakis Z, Kathopoulis N, Zacharakis D, Blontzos N, Antsaklis P, Haidopoulos D, Daskalakis G, Rodolakis A, Theodora M. Myomectomy during pregnancy; diagnostical dilemmas: two case reports and a systematic review of the literature. J OBSTET GYNAECOL 2022; 42:757-765. [PMID: 35264054 DOI: 10.1080/01443615.2022.2036976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Myomectomy in pregnancy, until this day, remains very controversial. We present two cases of successful antepartum myomectomies performed in the second trimester of gestation. In both cases, the initial suspected origin of these tumours was the ovaries. However, as it was shortly after confirmed, since both women underwent laparotomy, the diagnosis of these masses was uterine fibroids. Both cases resulted on the live birth of two healthy infants via caesarean section. Secondarily, we conducted a thorough review of current data of myomectomies performed during pregnancy, including the characteristics and diagnosis of the myomas of pregnant women, the surgical details and complications, along with the outcomes of these gestations. Overall, the analysis of cases published in international literature, suggests that the surgical removal of myomas during pregnancy can be considered safe, given certain indications and considerations. Our review comprises of 71 women undergoing excision of fibroids during pregnancy. Only three cases ended in a miscarriage while the remaining 68 resulted in a second or third trimester delivery. However, the data concerning the safety of the procedure are scarce and originate mostly from case reports. Thus, conclusions on the exact maternal and obstetrical complication rates cannot be drawn.
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Affiliation(s)
- Michail Diakosavvas
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Kyveli Angelou
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Zacharias Fasoulakis
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kathopoulis
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitris Zacharakis
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Blontzos
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Antsaklis
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Haidopoulos
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Daskalakis
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rodolakis
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Theodora
- 1st Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
We discuss five technical modifications made over 8 years in the technique of robotic myomectomy at our institution. Universal preoperative MRI was the first modification. Precise hysterotomy incisions were planned by accurate myoma mapping. The second modification was to reduce the number of ports. We performed surgery with one 12-mm-port for the camera and one 8-mm-port on either side of the patient for scissors and fenestrated bipolar forceps. Third modification was to reduce the number of robotic instruments by using laparoscopic myoma screw instead of robotic tenaculum during enucleation and discard the use of a second needle driver and prograsp forceps. So instead of six instruments in classical technique, we now use only three instruments thus reducing the cost of instruments by 40-50%. The fourth modification was to use a single 30 or 45 cm barbed suture. A single long suture efficiently managed by wristed needle driver of robot was sufficient in most cases for hysterotomy closure. This reduces the time needed for multiple needle pass and cost due to reduced number of sutures used. The fifth modification was to not use the electro mechanical morcellator and commercially available bags. We do cold knife morcellation in indigenous plastic bags. Over a period of eight years, we have made robotic myomectomy efficient and reduced the cost of instruments by 40-50% as compared to the classical technique. This has enabled wider adoption of robotic myomectomy at our institution thus reducing open myomectomy in all types of myomas.
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Das R, Wale A, Renani SA, Ratnam L, Mailli L, Chun JY, Das S, Duggal B, Manyonda I, Belli AM. Randomised Controlled Trial of Particles Used in Uterine fibRoid Embolisation (PURE): Non-Spherical Polyvinyl Alcohol Versus Calibrated Microspheres. Cardiovasc Intervent Radiol 2022; 45:207-215. [PMID: 34984488 PMCID: PMC8807446 DOI: 10.1007/s00270-021-02977-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 08/18/2021] [Indexed: 11/30/2022]
Abstract
Purpose The PURE study is a randomised controlled trial (RCT) comparing the clinical and MRI outcomes of patients treated with non-spherical polyvinyl alcohol, ns-PVA (Contour PVA–Boston Scientific–355–500 & 500–700 microns) versus calibrated hydrogel microspheres (Embozene–Varian Inc–700 & 900 microns) for symptomatic uterine fibroids. Materials and Methods Prospective, ethically approved non-sponsored RCT in 84 patients in a single UK tertiary IR unit, ISRCTN registry trial number ISRCTN18191539 in 2013 and 2014. All patients with symptomatic fibroid disease were eligible. UAE followed a standardised protocol with UFS-QOL and contrast-enhanced MRI before and 6 months post UAE. Outcome measures included: (1) Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL). (2) Percentage total and dominant fibroid infarction. (3) Uterine and dominant fibroid volume reduction. (4) Volume of embolics. Results Sixty-three patients completed the QOL follow-up (33 ns-PVA vs 30 Embozenes), the groups were equivalent at baseline. Patients were followed up for 6 months following UAE. There was no significant difference in symptom scores or HR-QOL between ns-PVA and Embozenes, p = 0.67 and 0.21, respectively. 92.7% of patients treated with ns-PVA achieved > 90% dominant fibroid infarction versus 61.8% treated with Embozenes (p = 0.0016). 66% of patients treated with ns = PVA achieved > 90% total fibroid percentage infarction compared with 35% in the Embozene group (p = 0.011). The mean vials/syringes used were 5.2 with Embozenes versus 4.1 using PVA (p = 0.08). Conclusion The PURE study informs IRs regarding the efficacy of embolic agents in UAE, with superior fibroid infarction on MRI using ns-PVA versus Embozenes however no significant difference in clinical outcomes at 6 months after UAE. Supplementary Information The online version contains supplementary material available at 10.1007/s00270-021-02977-0.
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Affiliation(s)
- Raj Das
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK.
| | - Anita Wale
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Seyed Ameli Renani
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Lakshmi Ratnam
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Leto Mailli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Joo-Young Chun
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
| | - Sourav Das
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Balpreet Duggal
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Isaac Manyonda
- Department of Gynaecology, St. George's Hospital, London, UK
| | - Anna-Maria Belli
- Department of Radiology, St. George's Hospital, St George's Healthcare NHS Trust, London, SW17 0QT, UK
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Piriyev E, Schiermeier S, Bends R, Römer T. Transcervical radiofrequency ablation of fibroids that are 5 cm or larger in women with abnormal uterine bleeding. J Gynecol Obstet Hum Reprod 2021; 51:102303. [PMID: 34973479 DOI: 10.1016/j.jogoh.2021.102303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Fibroids are the most common benign uterine tumors. Transcervical radiofrequency ablation with the Sonata® System offers a minimally invasive, incisionfree, organ-preserving therapy, with intraoperative visualization of fibroids using intrauterine ultrasound guidance. To demonstrate the effectiveness of transcervical radiofrequency ablation of fibroids that are 5 cm or larger using the Sonata® System, this retrospective analysis was collected. METHOD 151 patients have been treated with this method in our department up to the time of this analysis. Only patients with at least one fibroid of ≥5 cm and with bleeding symptoms, who were treated with the Sonata® System were included in this retrospective study. A total of 50 patients were included in the study and 57 fibroids were treated. RESULTS A total of 57 fibroids were detected and treated, however FIGO 1 and 2 fibroids (in total three fibroids were excluded). The smallest fibroid was 4 cm and the largest fibroid was 12 cm. A single ablation was performed in 18 cases, two ablation steps in 16 cases, three ablation steps in 13 cases, and more than three ablation steps in three cases. Depending on ablation steps, the shortest ablation time was 3 min 15 s and the longest ablation time was 25 min 6 s, with an average time of 9 min 12 s. 86% of patients reported an improvement of symptoms Conclusion: Thus, the Sonata® System is a simple, minimally invasive, rapid and successful method that shows significant improvement of symptoms even in large myomas from ≥5 cm.
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Affiliation(s)
- Elvin Piriyev
- University Witten-Herdecke, Department of Obstetrics and Gynecology, Academic Hospital Cologne Weyertal University of Cologne, Germany.
| | - Sven Schiermeier
- Department of Obstetrics and Gynecology, University Witten-Herdecke, Marien-Hospital, Witten Marienplatz, 258452, Witten, Germany
| | - Ralf Bends
- Department of Obstetrics and Gynecology Academic Hospital Cologne Weyertal University of Cologne, Germany
| | - Thomas Römer
- Department of Obstetrics and Gynecology Academic Hospital Cologne Weyertal University of Cologne, Germany
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Abstract
Intraligamental leiomyomas are usually small and asymptomatic. On very rare occasions, it can become so enlarged as to occupy the whole abdominopelvic cavity. Here, we report the clinical presentations and peri-operative management of two cases with massive intraligamental leiomyoma which weighed 11.1 kg and 3.7 kg respectively. Both of the cases presented with indolent symptoms lasting for months. One patient underwent hysterectomy, whereas the other underwent myomectomy. The postoperative courses were uneventful. Huge intraligamental leiomyomas are challenges even for experienced surgeons and thus need careful attention. The operation for every patient should be individualized to avoid the risk of injury to adjacent organs and incur massive blood loss.
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Affiliation(s)
- Chia-Yi Lee
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Hsin-Chu Branch, Hsin-Chu City, 300, Taiwan
| | - Chi-Hau Chen
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, 100, Taiwan.
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Mathew RP, Francis S, Jayaram V, Anvarsadath S. Uterine leiomyomas revisited with review of literature. Abdom Radiol (NY) 2021; 46:4908-26. [PMID: 34057564 DOI: 10.1007/s00261-021-03126-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/07/2021] [Accepted: 05/19/2021] [Indexed: 01/10/2023]
Abstract
Uterine leiomyomas, more commonly known as fibroids, are the most common neoplasms of the uterus. These tumors have a profound effect on health care and cost worldwide. Depending on the race, uterine leiomyomas can be seen in 70-80% of all women. Although majority of the women with uterine leiomyomas remain asymptomatic, approximately 30% can present with symptoms. Diagnosing typical leiomyomas on imaging is straightforward. However, when large, located extrauterine and especially with degeneration, the diagnosis can be challenging on imaging. In this article, apart from reviewing the demographics and management of patients with leiomyomas, we describe in detail the imaging appearance of various atypical leiomyomas, uncommon locations outside the uterus and their important differential diagnosis that can have a profound effect on patient management.
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Jagannathan JP, Steiner A, Bay C, Eisenhauer E, Muto MG, George S, Fennessy FM. Differentiating leiomyosarcoma from leiomyoma: in support of an MR imaging predictive scoring system. Abdom Radiol (NY) 2021; 46:4927-4935. [PMID: 34075468 DOI: 10.1007/s00261-021-03132-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/08/2021] [Accepted: 05/19/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The purpose of this study was to determine the Magnetic Resonance (MR) imaging features that best differentiate leiomyosarcoma (LMS) from leiomyoma, and to explore a scoring system to preoperatively identify those at highest risk of having LMS. METHODS Our Institutional Review Board approved this retrospective HIPAA-compliant study with a waiver for written informed consent. Institutional Research Patient Data Registry identified patients with histopathologically-proven LMS (n = 19) or leiomyoma (n = 25) and a pelvic MRI within six months prior to surgery. Qualitative differentiating MRI features were selected based on prior publications and clinical experience. Patient and MRI characteristics for leiomyomas versus LMS were compared using Wilcoxon rank-sum tests or Fisher's exact tests and using a basic classification tree. Hypothesis testing was two-tailed, with a p value < 0.001 used to determine inclusion of variables into an MR imaging predictive (MRP) score. Diagnostic performance [sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV)] of the MRP in diagnosis of LMS used all possible scores as cutoffs. RESULTS Seven out of 15 MRI features were found to have an association with LMS. The final MRP scores ranged from 0 to 7: a score of 0-3 was associated with 100% NPV for LMS, and a MRP score of 6-7 with 100% PPV for LMS. CONCLUSION Seven qualitative MR imaging features, extracted from a standard MR imaging protocol, allow differentiation of LMS from leiomyoma. An exploratory risk stratification MRP score can be used to determine the likelihood of LMS being present.
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Affiliation(s)
- Jyothi P Jagannathan
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Aida Steiner
- Department of Radiology, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20521, Turku, Finland
| | - Camden Bay
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
- Department of Medicine/Biostatistics, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Eric Eisenhauer
- Department of Gynecologic Oncology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02214, USA
| | - Michael G Muto
- Division of Surgical Oncology, Harvard Medical School, Dana Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Suzanne George
- Department of Medical Oncology, Harvard Medical School, Dana Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Fiona M Fennessy
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Lee WJ, Kim MD, Han K, Won YR, Alqahtani A, Moon S, An H. Potential benefit of GnRH-agonist treatment before uterine artery embolization for large fibroids: MRI prediction of fibroid volume reduction. Acta Radiol 2021; 63:1425-1432. [PMID: 34565214 DOI: 10.1177/02841851211038802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Signal intensity (SI) of predominant fibroid (F1) on T2-weighted (T2W) images is useful for predicting the volume reduction response after gonadotropin-releasing hormone (GnRH)-agonist treatment. Few studies have been published regarding when and how to use GnRH agonist before UAE. PURPOSE To investigate magnetic resonance imaging (MRI) prediction of volume reduction rate (VRR) of large fibroids after GnRH-agonist treatment before uterine artery embolization (UAE) as well as the efficacy of UAE based on MRI. MATERIAL AND METHODS Data from 30 patients with a large fibroid and MRI results both before and after GnRH-agonist treatment were retrospectively analyzed. Indications for GnRH-agonist treatment are fibroids with a maximum diameter ≥10 cm or pedunculated submucosal fibroids ≥8 cm. GnRH agonist (3.75 mg leuprolide acetate) was administered subcutaneously once per month 2-6 times. SI of F1 on T2W imaging was measured: the SI was referenced to the SI of the rectus abdominis muscle (F/R). RESULTS Mean maximum fibroid diameter was 11.1 ± 1.9 cm (range = 8.0-15.5 cm). Mean number of GnRH-agonist injections before UAE was 2.8 (range = 2-6). For predicting VRR ≥50% and <30%, the optimal cut-off values of F/R were 2.58 (sensitivity 80%, specificity 80%) and 1.69 (sensitivity 100%, specificity 70%), respectively. Of the 30 patients, fibroid infarction was complete in 29 (96.7%). CONCLUSION SI of F1 on T2W imaging is useful for predicting the volume reduction response after GnRH-agonist treatment. After GnRH-agonist treatment for large fibroids, UAE is effective to achieve complete infarction of fibroids.
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Affiliation(s)
- Woo Jin Lee
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Man-Deuk Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ye Ryung Won
- Department of Biostatistics and Computing, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Abdulrahman Alqahtani
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungmo Moon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyeongsu An
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Republic of Korea
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Ota K, Sato K, Shiraishi S, Takahashi T. Ageing impairs restoration of endometrial blood flow impedance after laparoscopic myomectomy in infertile women with uterine fibroids. J OBSTET GYNAECOL 2021; 42:1211-1216. [PMID: 34553647 DOI: 10.1080/01443615.2021.1945011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The aim of this study was to evaluate temporal changes in endometrial blood flow after laparoscopic myomectomy (LM). Nineteen infertile women with uterine fibroids who underwent LM were included. The uterine radial artery resistance index (RA-RI) and recovery index were measured before and at 1 week and 3 months after LM. The median RA-RI at 1 week but not 3 months after LM was significantly higher than before. The median recovery indexes at 1 week and 3 months after LM were 14.3% and 1.3%, respectively. Although there was no significant correlation between the patient's age and recovery index at 1 week (r = 0.28, p = .24) after LM, a moderately significant correlation was observed at 3 months (r = 0.54, p = .002). In conclusion, the endometrial blood flow after LM changed over time, and recovery of blood flow was negatively correlated with patient age.IMPACT STATEMENTWhat is already known on this subject? Uterine blood flow is important for wound healing after myomectomy, but no studies have evaluated endometrial blood flow after myomectomy.What do the results of this study add? The endometrial blood flow impedance of RA-RI increased after LM and returned to before surgery at 3 months postoperatively. RA-RI recovery index negatively correlated with patient age.What are the implications of these findings for clinical practice and/or further research? The changes in endometrial blood flow impedance after myomectomy suggest that endometrial blood flow may be involved in wound healing at the enucleation site. The impairment of endometrial blood flow recovery after myomectomy due to increased age may provide a rationale for individualised wound healing after myomectomy. The measurement of endometrial blood flow may be useful in personalising the assessment of the waiting period for pregnancy after myomectomy.
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Affiliation(s)
- Kuniaki Ota
- Fukushima Medical Center for Children and Women, Fukushima Medical University, Fukushima, Japan
| | - Kenji Sato
- Department of Obstetrics and Gynecology, Tokai University, Kanagawa, Japan
| | - Satoru Shiraishi
- Department of Obstetrics and Gynecology, Nasu Red Cross Hospital, Tochigi, Japan
| | - Toshifumi Takahashi
- Fukushima Medical Center for Children and Women, Fukushima Medical University, Fukushima, Japan
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Yamamoto A, Suzuki S. Successful surgical treatment of a giant uterine leiomyoma: A case report. Int J Surg Case Rep 2021; 87:106416. [PMID: 34537523 PMCID: PMC8449239 DOI: 10.1016/j.ijscr.2021.106416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction and importance Uterine leiomyoma is a common disease. The tumor gradually increases and becomes a target for treatment when accompanied by certain symptoms. It rarely grows into a giant uterine leiomyoma, which is defined as leiomyoma weighing >11.34 kg. Case presentation A 58-year-old Japanese woman had a history of putamen hemorrhage and deep vein thrombosis. A giant uterine leiomyoma prevented her from walking, and she scheduled surgery for its removal. The tumor was 46 × 35 × 27 cm, and the uterine arteries and veins were extremely dilated. A blocking balloon catheter was placed in the abdominal aorta to prevent massive bleeding, and a filter was placed in the inferior vena cava to prevent pulmonary thromboembolism. The surgery focused on careful vascular treatment, with selective ligation of the ovarian arteries and veins and the uterine arteries. The total amount of bleeding was 1130 g, and the uterus was removed without complications. The weight of the excised tissue was 22.6 kg. Clinical discussion Surgical treatment of the largest giant uterine leiomyomas is rare and challenging. Previous reports addressed the risk of massive bleeding and perioperative death. Surgery is the best treatment for giant uterine leiomyomas, but perioperative management and surgical procedures require complex and elaborate planning. Conclusion Very few gynecologists have experience treating giant uterine leiomyomas. Successful surgery requires careful surgical preparation, and the gynecological oncologist must have extensive experience with giant leiomyomas. Giant uterine leiomyomas are extremely rare. We report one of the world's largest cases of uterine leiomyoma. Surgical resection preceded by uterine artery ligation was successful. Sufficient preparation is necessary for safe surgery.
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Affiliation(s)
- Akihito Yamamoto
- Department of Obstetrics and Gynecology, Nippon Medical School, Japan.
| | - Shunji Suzuki
- Department of Obstetrics and Gynecology, Nippon Medical School, Japan
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Coll S, Feliu S, Montero C, Pellisé-Tintoré M, Tresserra F, Rodríguez I, Barri-Soldevila PN. Evolution of laparoscopic myomectomy and description of two hemostatic techniques in a large teaching gynecological center. Eur J Obstet Gynecol Reprod Biol 2021; 265:181-189. [PMID: 34509877 DOI: 10.1016/j.ejogrb.2021.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/11/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide a description of laparoscopic myomectomy and the two hemostatic techniques performed over the last 11 years in a single reference center for gynecology and obstetrics and to evaluate the factors associated with favorable surgical outcomes. STUDY DESIGN We retrospectively analyzed 625 who underwent laparoscopic myomectomy from January 2009 to December 2019. RESULTS Of 625 patients, 437 (69.8%) were symptomatic. The most common symptoms were heavy uterine bleeding (33.2%). 188 patients (30.1%) were asymptomatic but were operated in 77 cases (12.3%) for rapid fibroid growth, 32 (5.1%) for uterine cavity distortion and, in 45 cases (8.6%), the myomectomy was indicated during a surgery for other medical reason due to its accessibility. In 173 cases (27.9%) intramyometrial adrenaline was injected and in 246 cases (39.7%) a temporary blockage of the uterus blood supply was performed. Only 35 (5.6%) patients presented complications, of which, 14 (40%) were hemorrhagic. These hemorrhagic complications were more frequent when intramyometrial adrenaline was used (5,8%) than after the temporary clipping of the uterine arteries and infundibulopelvic ligaments (0,8%; p < 0,001). In the multivariate logistic regression model, the only factor statistically associated with favorable surgical outcome was the use of temporary clipping of the uterine arteries at their origin and infundibulopelvic ligaments as hemostatic technique during the surgery. CONCLUSION Laparoscopic myomectomy was generally safe with a high level of favorable outcomes. The temporary clipping of uterine arteries and infundibulopelvic ligaments presented fewer intraoperative bleedings compared with injecting intramyometrial adrenaline.
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Affiliation(s)
- Sandra Coll
- Department of Obstetrics, Gynecology and Assisted Reproduction, Hospital Universitari Dexeus, Barcelona, Spain.
| | - Silvia Feliu
- Department of Obstetrics, Gynecology and Assisted Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Claudia Montero
- Department of Obstetrics, Gynecology and Assisted Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Maria Pellisé-Tintoré
- Department of Obstetrics, Gynecology and Assisted Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Francesc Tresserra
- Department of Obstetrics, Gynecology and Assisted Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Ignacio Rodríguez
- Department of Obstetrics, Gynecology and Assisted Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
| | - Pere Nolasc Barri-Soldevila
- Department of Obstetrics, Gynecology and Assisted Reproduction, Hospital Universitari Dexeus, Barcelona, Spain
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Roberson JL, Krumeich LN, Darwich NF, Babatunde V, Laczko D, Albee A, Yang Z, Jack AE, Shlansky-Goldberg R, DeAgostino-Kelly M, Braslow BM. Fibroid expulsion: a unique presentation of mechanical small bowel obstruction 11 years after uterine artery embolization: a case report. J Med Case Rep 2021; 15:356. [PMID: 34238340 PMCID: PMC8268189 DOI: 10.1186/s13256-021-02917-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/19/2021] [Indexed: 11/11/2022] Open
Abstract
Background Uterine artery embolization in the treatment of uterine leiomyoma has been rarely associated with dislodgement and expulsion of infarcted uterine fibroids through the vagina, peritoneum, or bowel wall, predominantly occurring within 6 months of uterine artery embolization. Case presentation We present the case of a 54-year-old African American woman who underwent uterine artery embolization 11 years prior and developed mechanical small bowel obstruction from the migration of fibroid through a uteroenteric fistula with ultimate impaction within the distal small bowel lumen. Small bowel resection and hysterectomy were curative. Conclusions Uteroenteric fistula with small bowel obstruction due to fibroid expulsion may present as a delayed finding after uterine artery embolization and requires heightened awareness.
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Affiliation(s)
- Jeffrey L Roberson
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA.
| | - Lauren N Krumeich
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA, 19104, USA
| | - Nabil F Darwich
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Victor Babatunde
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Dorottya Laczko
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Andrew Albee
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Zhaohai Yang
- Department of Pathology & Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Amr El Jack
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | | | - Mary DeAgostino-Kelly
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Benjamin M Braslow
- Division of Trauma, Surgical Critical Care, and Emergency Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
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Ozen M, Momin S, Myers CB, Hoffman M, Raissi D. Primary bilateral ovarian artery embolization for uterine leiomyomatosis in the setting of a rare anatomic variant - hypoplastic uterine arteries. Radiol Case Rep 2021; 16:2426-2428. [PMID: 34257773 PMCID: PMC8260744 DOI: 10.1016/j.radcr.2021.05.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022] Open
Abstract
We present the case of a 50-year-old female who underwent bilateral ovarian artery embolization for uterine fibroids in the setting of hypoplastic uterine arteries. Ovarian artery embolization is usually conducted during uterine artery embolization for fibroids to increase the procedure success when ovarian feeders are seen. The bilateral ovarian artery embolization is rarely performed due to fears of amenorrhea and early menopause from decreased blood supply to both ovaries. According to our knowledge, this the first case report describing primary bilateral ovarian artery embolization in the setting of a rare anatomic variant- hypoplastic uterine arteries. The patient had complete resolution of symptoms from her uterine fibroids after treatment with bilateral ovarian artery embolization with no ovarian failure findings on the follow-up.
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Affiliation(s)
- Merve Ozen
- Department of Radiology, University of Kentucky College of Medicine, 800 Rose Street, Room HX-318, Lexington, KY,Corresponding author.
| | - Shezaan Momin
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, 5001 El Paso Drive, El Paso, TX
| | - Charles Ben Myers
- Department of Radiology, University of Kentucky College of Medicine, 800 Rose Street, Room HX-318, Lexington, KY
| | - Mark Hoffman
- Department of Obstetrics & Gynecology, University of Kentucky College of Medicine, 125 E Maxwell St Suite 140, Lexington, KY
| | - Driss Raissi
- Department of Radiology, University of Kentucky College of Medicine, 800 Rose Street, Room HX-318, Lexington, KY
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Jeng CJ, Long CY, Chuang LT. Comparison of magnetic resonance-guided high-intensity focused ultrasound with uterine artery embolization for the treatment of uterine myoma: A systematic literature review and meta-analysis. Taiwan J Obstet Gynecol 2021; 59:691-697. [PMID: 32917320 DOI: 10.1016/j.tjog.2020.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study aimed to compare the outcomes of magnetic resonance-guided (MR-g) high-intensity focused ultrasound (HIFU) with uterine artery embolization (UAE) for the treatment of uterine myoma. MATERIALS AND METHODS A systematic literature review and meta-analysis was conducted using database searches of Medline, Cochrane, EMBASE, and Google Scholar. Articles were searched through March 25, 2020. Outcomes of interest were Symptom Severity Score (SSS), Health-related Quality of Life (HRQoL), re-intervention rate, and rate of adverse reactions in patients with uterine myoma. RESULTS Four studies were included with a total of 207 patients with uterine myomas who received MR-g HIFU and 201 who received UAE. UAE was associated with a greater reduction in SSS, improved HRQoL, and a significantly lower re-intervention rate compared with MR-g HIFU in 3 of 4 included studies. No significant differences were found in the incidence and severity of adverse events between treatment arms in one study, but differences were observed in the percentage of adverse reactions in another. CONCLUSION Published evidence suggests that the efficacy of MR-g HIFU may not be superior to that of UAE in the treatment of uterine myoma.
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Affiliation(s)
- Cherng-Jye Jeng
- Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, Kaohsiung Medical University, Taiwan
| | - Cheng-Yu Long
- Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Taiwan; Department of Obstetrics and Gynecology, School of Medicine, Kaohsiung Medical University, Taiwan
| | - Linus T Chuang
- Department of Obstetrics and Gynecology, School of Medicine, Kaohsiung Medical University, Taiwan; Department of Obstetrics and Gynecology, Connecticut Health Network, The University of Vermont Larner College of Medicine, Danbury, Connecticut, USA.
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43
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Okohue JE, Ameh N, Onuh SO, Madugu NH. A Retrospective Review of the Outcome of Abdominal Myomectomies at a Fertility Centre in South-South Nigeria. West Afr J Med 2021; 38:526-530. [PMID: 34174179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Abdominal myomectomy is a treatment modality for uterine fibroids. Its outcome depends on related variables which include the size, number and location of the fibroids, age of the patient, surgery and method used to secure haemostasis. OBJECTIVE To determine the outcomes of abdominal myomectomies and related variables in a fertility centre in South-south Nigeria. METHODS A retrospective study of the records of all cases of abdominal myomectomies performed between August 1, 2010 and July 31, 2017. Medical records of the 146 patients who had abdominal myomectomy during the period under review were retrieved and relevant data extracted. Information collected included the presence or absence of intra-abdominal adhesions, duration of tourniquet use, number and weight of enucleated fibroid seedlings, intraoperative blood loss, complications and the number of patients who achieved pregnancy after myomectomy. Data were analyzed using ANALYSE IT® statistical package. RESULTS 146 patients underwent myomectomy during the period under review. The age range of the patients was 28-56 years (median 41 years). Almost all the patients (94.5%) had tourniquets applied to the uterus for hemostasis. The number of fibroids enucleated ranged from 1 to 154 and weighed between 0.02 and 2.8kg. Blood loss ranged from 100 to1500mls, 17.4% had post-operative fever, and one patient had bowel injury. Thirty-one patients (32.3%) who subsequently had in vitro fertilisation treatment achieved conception. CONCLUSION Fibroids, weighing >0.5kg, are associated with increased blood loss during abdominal myomectomy, and a previous myomectomy significantly increases the risk of adhesions. Careful patient selection and meticulous surgical techniques are necessary to avoid morbidity in this setting with a high rate of large uterine fibroids.
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Affiliation(s)
- J E Okohue
- Department of Obstetrics and Gynaecology, Fertility Unit, Gynescope Specialist Hospital, Rivers State, Nigeria
| | - N Ameh
- Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - S O Onuh
- Department of Obstetrics and Gynaecology, Fertility Unit, Deda Hospital, Abuja, Nigeria
| | - N H Madugu
- Department of Obstetrics and Gynaecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
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Otonkoski S, Sainio T, Komar G, Suomi V, Saunavaara J, Blanco Sequeiros R, Perheentupa A, Joronen K. Oxytocin selectively reduces blood flow in uterine fibroids without an effect on myometrial blood flow: a dynamic contrast enhanced MRI evaluation. Int J Hyperthermia 2021; 37:1293-1300. [PMID: 33207939 DOI: 10.1080/02656736.2020.1846792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Uterine fibroids are the most common benign neoplasms in women. The administration of intravenous oxytocin is known to increase the efficacy of a non-invasive thermal ablation method (MR-HIFU) for treating fibroids. However, it is not known whether this phenomenon is caused by the effect of the oxytocin on the myometrium or the fibroid itself. The objective of this study was to evaluate the influence of oxytocin on the blood flow of fibroids, myometrium and skeletal muscle using a quantitative perfusion MRI technique. MATERIALS AND METHODS 17 premenopausal women with fibroids considered to be treated with MR-HIFU and 11 women with no fibroids were enrolled in the study. An extended MRI protocol of the pelvis was acquired for each subject. Later another MRI scan was performed with continuous intravenous infusion of oxytocin. The effect of oxytocin was analyzed from quantitative perfusion imaging. The study was registered in clinicaltrials.gov NCT03937401. RESULTS Oxytocin decreased the blood flow of each fibroid; the median blood flow of fibroid was 39.9 ml/100 g tissue/min without and 3.5 mL/100 g/min with oxytocin (p ≤ 0.0001). Oxytocin did not affect the blood flow of the myometrium in either group. Oxytocin increased the blood flow of the skeletal muscle in both groups (p = 0.04). CONCLUSION Oxytocin is effective in decreasing the blood flow in fibroids while having minor or no effect on the blood flow of normal myometrium. Routine use of oxytocin in HIFU therapy may make the therapy suitable to a larger group of women in a safe manner.
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Affiliation(s)
- Saara Otonkoski
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Faculty of Medicine, Turku, Finland
| | - Teija Sainio
- Department of Radiology, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Gaber Komar
- University of Turku, Faculty of Medicine, Turku, Finland.,Department of Radiology, Turku University Hospital, Turku, Finland
| | - Visa Suomi
- University of Turku, Faculty of Medicine, Turku, Finland.,Department of Radiology, Turku University Hospital, Turku, Finland
| | - Jani Saunavaara
- Department of Radiology, Turku University Hospital, Turku, Finland.,Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Roberto Blanco Sequeiros
- University of Turku, Faculty of Medicine, Turku, Finland.,Department of Radiology, Turku University Hospital, Turku, Finland
| | - Antti Perheentupa
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Faculty of Medicine, Turku, Finland
| | - Kirsi Joronen
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.,University of Turku, Faculty of Medicine, Turku, Finland
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Murphy CA, Zarudskaya O, Kakish C, Zoorob D, Seo-Patel S. Uterine Fibroid in a 16-Year-Old Adolescent Managed with a Fertility-Sparing Approach: A Case Report and Review of the Literature. J Pediatr Adolesc Gynecol 2021; 34:427-431. [PMID: 33359317 DOI: 10.1016/j.jpag.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 12/10/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Uterine fibroids are the most common benign tumor of the uterus in adult women. However, it is exceedingly rare in adolescents. CASE A 16-year-old girl presented with severe anemia and abnormal uterine bleeding. MRI of the pelvis demonstrated a 9-cm mass within the uterus concerning for leiomyoma or leiomyosarcoma. A fertility preserving myomectomy led to the final diagnosis of a benign uterine fibroid. SUMMARY AND CONCLUSION Despite the rare incidence of leiomyomas in adolescents, it is imperative that it is included in the differential diagnosis when young women present with abnormal uterine bleeding. A less common diagnosis to consider is leiomyosarcoma; however, this is histologically diagnosed. Thus, a fertility-preserving myomectomy permits for a diagnostic opportunity to rule out a potential malignancy.
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Affiliation(s)
- Courtney A Murphy
- Department of Obstetrics and Gynecology, University of Toledo Medical Center, Toledo, Ohio.
| | - Oxana Zarudskaya
- Department of Obstetrics and Gynecology, University of Toledo Medical Center, Toledo, Ohio
| | - Carmen Kakish
- Department of Obstetrics and Gynecology, University of Toledo Medical Center, Toledo, Ohio
| | - Dani Zoorob
- Department of Obstetrics and Gynecology, University of Toledo Medical Center, Toledo, Ohio
| | - Sonyoung Seo-Patel
- Department of Obstetrics and Gynecology, ProMedica Toledo Hospital, Toledo, Ohio
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Abstract
Background Routine myomectomy at the time of cesarean section has been condemned in the past due to fear of uncontrolled hemorrhage and peripartum hysterectomy. It is still a topic of debate worldwide. However, in recent years, many case studies of cesarean myomectomy have been published validating its safety without any significant complications. Case presentation We describe the case of a 27-year-old gravida 2 para 1 live birth 1 North Indian woman with one previous lower segment caesarean section (LSCS) at 35 weeks with labor pains and scar tenderness. Her recent ultrasound (USG) report suggested a single live intrauterine pregnancy with an intramural fibroid of 8.6 × 6.5 cm located in the left anterolateral wall of the lower uterine segment. The patient was taken up for emergency cesarean section along with successful removal of the myoma, which was bulging into the incision line, causing difficulty in closure of the uterine wound. Prophylactically, oxytocin infusion, bilateral ligation of uterine arteries, and injection vasopressin (diluted) was administered to decrease the blood loss. The patient was discharged after 7 days without any complications. Conclusions Routine myomectomy at the time of cesarean section is not a standard procedure and is not accepted worldwide. However, it may be considered a safe option in carefully selected cases in the hands of an experienced obstetrician with appropriate hemostatic technique. Large multicenter randomized controlled trials should be conducted to evaluate the best practice guidelines for cesarean myomectomy.
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Affiliation(s)
- Priyanka Garg
- Department of Obstetric and Gynecology, All India Institute of Medical Sciences, Bathinda, 151505, India. .,Department of Obstetric and Gynecology, Adesh institute of Medical Sciences and Research, Bathinda, Punjab, India.
| | - Romi Bansal
- Department of Obstetric and Gynecology, Adesh institute of Medical Sciences and Research, Bathinda, Punjab, India
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47
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Somigliana E, Reschini M, Bonanni V, Busnelli A, Li Piani L, Vercellini P. Fibroids and natural fertility: a systematic review and meta-analysis. Reprod Biomed Online 2021; 43:100-110. [PMID: 33903032 DOI: 10.1016/j.rbmo.2021.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 01/26/2021] [Accepted: 03/16/2021] [Indexed: 02/02/2023]
Abstract
Available evidence from IVF studies supports a detrimental effect of submucosal and intramural fibroids on embryo implantation. It is misleading, however, to infer evidence obtained in IVF settings to natural fertility. Therefore, a systematic review and meta-analysis was conducted on the effect of fibroids on natural fertility. Studies comparing fertile and infertile women, and those investigating whether the presence of fibroids was a risk factor, were reviewed, as well as studies comparing women with and without fibroids. The aim was also to establish whether the frequency of infertility differed between the two groups. Seven out of 11 selected studies did not aim to establish whether fibroids caused infertility but, rather, whether a history of infertility could be a risk factor for fibroids. A meta-analysis of the four remaining studies that concomitantly evaluated the presence of fibroids and infertility studies highlighted a common odds ratio of fibroids in subfertile women of 3.54 (95% CI 1.55 to 8.11). When focusing on the two most informative studies, i.e. the studies comparing time to pregnancy in women with and without fibroids, the common OR was 1.93 (95% CI 0.89 to 4.18). In conclusion, the association between fibroids and infertility has been insufficiently investigated. Epidemiological studies suggest, but do not demonstrate, that fibroids may interfere with natural fertility. Given the high prevalence of these lesions in women seeking pregnancy, further evidence is urgently needed.
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Affiliation(s)
- Edgardo Somigliana
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, Milan 20122, Italy.
| | - Marco Reschini
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, Milan 20122, Italy
| | - Valentina Bonanni
- Department of Gynecology, Obstetrics and Urology, 'Sapienza' University of Rome, Rome, Italy
| | - Andrea Busnelli
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele Milan, Italy; IRCCS Humanitas Research Hospital, Department of Gynecology, Division of Gynecology and Reproductive Medicine, Fertility Center, Rozzano Milan, Italy
| | - Letizia Li Piani
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, Milan 20122, Italy
| | - Paolo Vercellini
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via M. Fanti, 6, Milan 20122, Italy
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Giordano T, MacDonald W. Thoracic endometriosis presenting as recurrent pleural effusions. Radiol Case Rep 2021; 16:250-253. [PMID: 33304436 PMCID: PMC7708763 DOI: 10.1016/j.radcr.2020.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 10/25/2022] Open
Abstract
In rare instances, endometrial glandular tissue can implant in the thorax of women suffering from endometriosis. The presentation is variable depending on site of implant and can be a rare cause of hemothorax in women. A 28-year-old woman presented with shortness of breath and was found to have a significant right sided hemothorax. The hemothorax was drained but subsequently recurred, with shortness of breath increasing around the time of her menses. Considerable workup was performed and ultimately surgery was required to diagnose her with thoracic endometriosis. This case describes how thoracic endometriosis is a challenging diagnosis and may be under reported in the literature. However, there are key elements of the disease that can prevent delay in diagnosis to reduce pain and suffering.
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Affiliation(s)
- Taylor Giordano
- Department of Radiology, Aurora St. Luke's, 2900 W Oklahoma Ave, Milwaukee, WI 53215, USA
| | - William MacDonald
- Department of Radiology, Aurora St. Luke's, 2900 W Oklahoma Ave, Milwaukee, WI 53215, USA
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Cornman-Homonoff J, Zhou ZN, Fenster TB, Schiffman MH. Combination uterine artery embolization and hysteroscopic resection for a symptomatic uterine leiomyoma: A collaborative single-session approach for better patient care. Clin Imaging 2021; 77:111-116. [PMID: 33667943 DOI: 10.1016/j.clinimag.2021.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/09/2021] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
Uterine artery embolization (UAE) for symptomatic uterine fibroids is accompanied by transcervical fibroid expulsion in 3-15% of cases. It can be a source of significant patient distress, may require reintervention for removal, and is the most common reason for hospital readmission following UAE. Conversely, the success of hysteroscopic resection decreases with increasing fibroid size while the risk of complications increases. Because certain fibroid features identifiable on preoperative imaging predict need for eventual hysteroscopic resection, it is possible to prospectively identify such patients and employ an alternative management strategy. We present such an approach, illustrated in the case of a woman with a pedunculated broad-based uterine fibroid successfully managed via combination UAE and immediate hysteroscopic resection.
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Affiliation(s)
- Joshua Cornman-Homonoff
- The Department of Radiology and Biomedical Imaging, Division of Interventional Radiology, Yale New Haven Hospital, New Haven, CT, USA.
| | - Zhen Ni Zhou
- The Department of Obstetrics and Gynecology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Tamatha B Fenster
- The Department of Obstetrics and Gynecology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Marc H Schiffman
- The Department of Radiology, Division of Interventional Radiology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
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50
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Borghese G, Raffone A, Raimondo D, Saccone G, Travaglino A, Degli Esposti E, Mastronardi M, Salucci P, Zullo F, Seracchioli R. Adhesion barriers in laparoscopic myomectomy: Evidence from randomized clinical trials. Int J Gynaecol Obstet 2021; 152:308-320. [PMID: 33237574 DOI: 10.1002/ijgo.13495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/07/2020] [Accepted: 11/20/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of different adhesion barriers in the prevention of de novo adhesion development after laparoscopic myomectomy. METHODS A systematic review was performed by searching seven electronic databases for all randomized clinical trials (RCTs) comparing the use of any absorbable adhesion barrier (i.e. intervention group) with either no treatment or placebo (i.e. control group) in the prevention of adhesion development after laparoscopic myomectomy. RESULTS Eight RCTs with a total of 748 participants (392 in the intervention group and 356 in the control group) were included. The assessed adhesion barrier methods were: oxidized regenerated cellulose (ORC) in two studies, auto-crosslinked hyaluronic acid (HA) gel in two studies, 4% icodextrin solution in one study, modified HA and carboxy-methylcellulose in one study, polyethylene glycol ester trilysine amine solution plus a borate buffer solution in one study, and polyethylene glycol amine plus dextran aldehyde polymers in another study. CONCLUSION Adhesion barrier methods showing the most promising results were: ORC, auto-crosslinked HA gel, and polyethylene glycol amine plus dextran aldehyde polymers.
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Affiliation(s)
- Giulia Borghese
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Diego Raimondo
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gabriele Saccone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Eugenia Degli Esposti
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Manuela Mastronardi
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Paolo Salucci
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Fulvio Zullo
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
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